Anhydrous sodium thiosulfate and formulations thereof

ABSTRACT

Described herein is anhydrous sodium thiosulfate, methods for synthesizing anhydrous sodium thiosulfate, pharmaceutical compositions thereof, and methods of treating ototoxicity. Anhydrous sodium thiosulfate is synthesized from sodium sulfite, sulfur, and cetylpyridinium chloride. The anhydrous sodium thiosulfate is formulated into a pharmaceutical composition comprising a buffer and solvent. These compositions are useful for eliminating or reducing ototoxicity in pediatric patients receiving platinum based chemotherapeutics.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. application Ser. No.16/458,261, filed Jul. 1, 2019, which claims benefit of U.S. ProvisionalPatent Application Nos. 62/693,502 and 62/693,503, both filed on Jul. 3,2018, the entire contents of which are hereby incorporated herein byreference. Additionally, U.S. patent application Ser. No. 16/458,267,titled “FORMULATIONS OF ANHYDROUS SODIUM THIOSULFATE,” filed on Jul. 1,2019, is incorporated by reference herein in its entirety.

TECHNICAL FIELD

Described herein is anhydrous sodium thiosulfate, methods forsynthesizing anhydrous sodium thiosulfate, and pharmaceuticalcompositions thereof. These compositions are useful for eliminating orreducing ototoxicity in patients receiving platinum-basedchemotherapeutics.

BACKGROUND

Platinum based therapeutics are highly important components of treatmentregimens used in a variety of pediatric malignancies includingneuroblastoma, hepatoblastoma, medulloblastoma, osteosarcoma, malignantgerm cell tumors, and nasopharyngeal carcinomas. At commonly used dosesand schedules, platinum based therapeutics, such as cisplatin andcarboplatin, frequently cause hearing loss that is progressive,bilateral, irreversible, and often accompanied by tinnitus. Platinumchemotherapeutic based hearing loss can affect all hearing frequenciesowing to the death of cochlear outer hair cells.

These toxicities can be dose limiting and are often clinicallysignificant, especially in young children who are critically dependentupon normal hearing for cognitive, psychosocial, and speech development.Approximately 40% of children develop cisplatin-induced hearing losswith nearly 100% incidence for certain vulnerable groups. The effects ofeven mild hearing loss in pediatrics is substantial with, inter alia,reduced language acquisition, learning, academic performance, social andemotional development, and life quality. Thus, there is a need for safeand effective pharmaceutical compositions and methods for treatingpediatric patients to reduce ototoxicity and hearing loss in thesepatients that do not compromise the efficacy of the platinum-basedtherapeutic.

SUMMARY

One embodiment described herein is anhydrous sodium thiosulfatecharacterized by an X-ray powder diffraction (XRPD) pattern comprisingat least four peaks selected from 10.52, 15.13, 17.71, 19.70, 21.09,21.49, 21.84, 27.40, 28.96, 30.46, 31.81, 32.52, 33.15, 37.40, or 38.16degrees 2 theta (2 θ)±0.2, when the XRPD is collected from about 2 toabout 40 degrees 2 θ using copper Kα radiation. In one aspect, theanhydrous sodium thiosulfate is characterized by an X-ray powderdiffraction (XRPD) pattern comprising at least four peaks selected from10.52, 15.13, 19.70, 21.49, 21.84, 28.96, 30.46, 33.15, 37.40, and 38.16degrees 2 theta (2 θ)±0.2, when the XRPD is collected from about 2 toabout 40 degrees 2 θ using copper Kα radiation. In another aspect, theanhydrous sodium thiosulfate is characterized by a differential scanningcalorimetry melting onset of about 331° C.; and a thermogravimetricanalysis showing negligible weight loss from ambient temperature to 162°C., a weight loss of 14.8% from 162° C. to 309° C., and an onset ofdecomposition at 436° C.

Another embodiment described herein is anhydrous sodium thiosulfatecomprising: no greater than 0.1 μg/g of cadmium; no greater than 0.25μg/g lead; no greater than 0.75 μg/g arsenic; no greater than 0.15 μg/gmercury; no greater than 0.25 μg/g cobalt; no greater than 0.5 μg/gvanadium; no greater than 1.0 μg/g nickel; no greater than 12.5 μg/glithium; no greater than 4.5 μg/g antimony; no greater than 15.0 μg/gcopper; no greater than 1500 ppm methanol; no greater than 3% (w/w)water; and no greater than 1.65% (w/w) of total impurities or relatedsubstances.

Another embodiment described herein is a method for synthesizing sodiumthiosulfate comprising reacting sodium sulfite with sulfur in thepresence of a surface acting agent. In one aspect, the surface actingagent comprises cetylpyridinium chloride. In another aspect, thereaction is aqueous. In another aspect, the reaction is conducted atabout 80° C. to about 100° C. In another aspect, the sodium thiosulfateis crystallized and washed with acetone.

Another embodiment described herein is a method for synthesizinganhydrous sodium thiosulfate comprising reacting sodium sulfite withsulfur in the presence of cetylpyridinium chloride and dehydratingsodium thiosulfate product. In one aspect, the reaction comprises 1.0mole equivalent of sodium sulfite; 1.1 mole equivalents of sulfur; and0.00013 mole equivalents of cetylpyridinium chloride. In another aspect,the reaction is aqueous. In another aspect, the reaction is conducted atabout 80° C. to about 100° C. In another aspect, the sodium thiosulfateis crystallized and washed with acetone. In another aspect, the sodiumthiosulfate is dehydrated and washed with methanol. In another aspect,the sodium thiosulfate is dried.

Another embodiment described herein is a method for synthesizinganhydrous sodium thiosulfate comprising: (a) reacting aqueous sodiumsulfite with sulfur and cetylpyridinium chloride; (b) crystallizingsodium thiosulfate and washing with acetone; (c) dehydrating the washedsodium thiosulfate with methanol; and (d) drying the dehydrated sodiumthiosulfate. In one aspect, the reaction comprises 1.0 mole equivalentof sodium sulfite; 1.1 mole equivalents of sulfur; and 0.00013 moleequivalents of cetylpyridinium chloride.

Another embodiment described herein is a method for synthesizinganhydrous sodium thiosulfate comprising: (a) reacting 1.0 moleequivalent of aqueous sodium sulfite with 1.1 mole equivalents of sulfurin the presence of 0.00013 mole equivalents of cetylpyridinium chlorideat about 90° C. to about 100° C.; (b) crystallizing sodium thiosulfateat <2° C. and washing with acetone; (c) dehydrating the washed sodiumthiosulfate with methanol; and (d) drying the dehydrated sodiumthiosulfate at about 25° C. to about 60° C.

Another embodiment described herein is anhydrous sodium thiosulfatesynthesized by the methods described herein.

Another embodiment described herein is a means for synthesizinganhydrous sodium thiosulfate comprising reacting sodium sulfite withsulfur in the presence of cetylpyridinium chloride, crystallizing thesodium thiosulfate product, and dehydrating sodium thiosulfate product.

Another embodiment described herein is anhydrous sodium thiosulfatesynthesized by the means described herein.

Another embodiment described herein is anhydrous sodium thiosulfatecomprising essentially no sodium thiosulfate pentahydrate.

Another embodiment described herein is a method for measuring thebinding capacity of sodium thiosulfate for cisplatin comprising: (a)mixing one or more ratios of sodium thiosulfate with a predeterminedquantity of cisplatin; (b) incubating the mixture for a period of time;and (c) analyzing the apparent concentration of cisplatin. In oneaspect, the ratios of sodium thiosulfate to cisplatin comprise 10:1 to1:1. In another aspect, the ratios of sodium thiosulfate to cisplatincomprise 10:1, 6:1, and 5:1. In another aspect, the incubation period oftime comprises 1 min to 180 min. In another aspect, the incubationperiod of time comprises about 5 min; about 35 min, about 65 min; andabout 95 min. In another aspect, the analyzing comprises HPLC and UVdetection.

Another embodiment described herein is a pharmaceutical compositioncomprising sodium thiosulfate, one or more buffers, and a solvent.Another embodiment described herein is a pharmaceutical compositioncomprising anhydrous sodium thiosulfate. Another embodiment describedherein is a pharmaceutical composition comprising anhydrous sodiumthiosulfate. Another embodiment described herein is a pharmaceuticalcomposition consisting essentially of anhydrous sodium thiosulfate.Another embodiment described herein is a pharmaceutical compositionconsisting essentially of aqueous anhydrous sodium thiosulfate.

Another embodiment described herein is a pharmaceutical compositioncomprising anhydrous sodium thiosulfate, and one or more buffers.Another embodiment described herein is a pharmaceutical compositionconsisting of anhydrous sodium thiosulfate, and one or more buffers. Inone aspect, the composition comprises about 20 mg to 32 g of anhydroussodium thiosulfate. In another aspect, the composition comprises about98% by mass of anhydrous sodium thiosulfate. In another aspect, thecomposition is a dry powder. In another aspect, the composition is alyophilized solution.

Another embodiment described herein is a pharmaceutical compositioncomprising aqueous anhydrous sodium thiosulfate, one or more buffers,and a solvent. Another embodiment described herein is a pharmaceuticalcomposition consisting essentially of anhydrous sodium thiosulfate, oneor more buffers, and a solvent.

Another embodiment described herein is a pharmaceutical compositioncomprising about 0.1 M to about 2 M of aqueous anhydrous sodiumthiosulfate, 0.001 M to about 0.5 M of one or more buffers, and water.Another embodiment described herein is a pharmaceutical compositioncomprising about 0.1 M to about 2 M of aqueous anhydrous sodiumthiosulfate, 0.01 M to about 0.5 M of sodium phosphate, pH 6.5, andwater. Another embodiment described herein is a pharmaceuticalcomposition comprising about 0.1 M to about 2 M of aqueous anhydroussodium thiosulfate, 0.001 M to about 0.5 M of boric acid or a saltthereof, pH 8.6-8.8, and water. Another embodiment described herein is apharmaceutical composition comprising about 0.1 M to about 2 M ofaqueous anhydrous sodium thiosulfate, 0.001 M to about 0.5 M of glycineor a salt thereof, pH 8.5-8.9, and water. Another embodiment describedherein is a pharmaceutical composition comprising about 0.1 M to about 2M of aqueous anhydrous sodium thiosulfate, 0.001 M to about 0.5 M oftris(hydroxymethyl)aminomethane (tromethane) or a salt thereof, pH8.5-8.9, and water.

Another embodiment described herein is a pharmaceutical compositioncomprising about 0.5 M of aqueous anhydrous sodium thiosulfate, about0.01 M of sodium phosphate, pH 6.5, and water. Another embodimentdescribed herein is a pharmaceutical composition comprising about 0.5 Mof aqueous anhydrous sodium thiosulfate, about 0.004 M of boric acid ora salt thereof, pH 8.6-8.8, and water. Another embodiment describedherein is a pharmaceutical composition comprising about 0.5 M of aqueousanhydrous sodium thiosulfate, about 0.01 M to about 0.05 M of glycine,pH 8.5-8.9, and water. Another embodiment described herein is apharmaceutical composition comprising about 0.1 M to about 2 M ofaqueous anhydrous sodium thiosulfate, 0.001 M to about 0.5 M oftris(hydroxymethyl)aminomethane (tromethane) or a salt thereof, pH8.5-8.9, and water.

Another embodiment described herein is a pharmaceutical compositioncomprising aqueous anhydrous sodium thiosulfate, one or more buffers,and a solvent. In one aspect, the composition comprises about 20 mg/mLto 320 mg/mL of aqueous anhydrous sodium thiosulfate. In another aspect,the composition comprises about 8% by mass to about 32% by mass ofaqueous anhydrous sodium thiosulfate. In another aspect, the compositioncomprises about 0.1 M to about 2 M of aqueous anhydrous sodiumthiosulfate. In another aspect, the composition comprises about 0.001 Mto about 0.5 M of the one or more buffers. In another aspect, the one ormore buffers comprise phosphate, sulfate, carbonate, borate, formate,acetate, propionate, butanoate, lactate, glycine, maleate, pyruvate,citrate, aconitate, isocitrate, α-ketoglutarate, succinate, fumarate,malate, oxaloacetate, aspartate, glutamate,tris(hydroxymethyl)aminomethane (tromethamine), combinations thereof, orsalts thereof. In another aspect, the composition has a pH of about 5 toabout 9.5. In another aspect, the composition has a pH of about 6.5 orabout 8.9. In another aspect, the one or more buffers comprise borate ora salt thereof, glycine or a salt thereof,tris(hydroxymethyl)aminomethane (tromethamine) or a salt thereof, orphosphate or a salt thereof. In another aspect, the one or more bufferscomprise boric acid, glycine, tris(hydroxymethyl)aminomethane(tromethamine), or sodium phosphate. In another aspect, the solventcomprises water. In another aspect, the composition is sterile.

Another embodiment described herein is a pharmaceutical compositioncomprising about 0.1 M to about 2 M of aqueous anhydrous sodiumthiosulfate, 0.001 M to about 0.5 M of sodium phosphate or boric acid.In one aspect, the composition comprises about 0.5 M of aqueousanhydrous sodium thiosulfate, and about 0.01 M of sodium phosphate, pH6.5. In another aspect, the composition comprises about 0.5 M of aqueousanhydrous sodium thiosulfate and about 0.004 M of borate or a saltthereof, pH 8.6-8.8. In another aspect, the composition comprises about0.5 M of aqueous anhydrous sodium thiosulfate and about 0.01 M to about0.05 M of glycine or a salt thereof, pH 8.5-8.9. In another aspect, thecomposition comprises about 0.5 M of aqueous anhydrous sodiumthiosulfate and about 0.01 M to about 0.05 M oftris(hydroxymethyl)aminomethane (tromethamine) or a salt thereof, pH8.5-8.9.

Another embodiment described herein is a pharmaceutical compositioncomprising about 0.5 M of aqueous anhydrous sodium thiosulfate, about0.01 M of sodium phosphate, pH 6.5, and water.

Another embodiment described herein is a pharmaceutical compositioncomprising about 0.5 M of aqueous anhydrous sodium thiosulfate, about0.004 M of borate or a salt thereof, pH 8.6-8.8, and water.

Another embodiment described herein is a pharmaceutical compositioncomprising about 0.5 M of aqueous anhydrous sodium thiosulfate, about0.01 M to about 0.05 M of glycine or a salt thereof, pH 8.5-8.9, andwater.

Another embodiment described herein is a pharmaceutical compositioncomprising about 0.5 M of aqueous anhydrous sodium thiosulfate, about0.01 M to about 0.05 M of tris(hydroxymethyl)aminomethane (tromethamine)or a salt thereof, pH 8.5-8.9, and water.

Another embodiment described herein is a method for preparing apharmaceutical formulation comprising anhydrous sodium thiosulfate, themethod comprising combining anhydrous sodium sulfate with one or morebuffers and a solvent. In one aspect, the method further comprisingfiltering and sterilizing the formulation. In another aspect, theformulation comprises about 20 mg/mL to 320 mg/mL of aqueous anhydroussodium thiosulfate. In another aspect, the formulation comprises about8% by mass to about 32% by mass of aqueous anhydrous sodium thiosulfate.In another aspect, the formulation comprises about 0.1 M to about 2 M ofaqueous anhydrous sodium thiosulfate. In another aspect, the formulationcomprises about 0.001 M to about 0.5 M of the one or more buffers. Inanother aspect, the one or more buffers comprise phosphate, sulfate,carbonate, formate, acetate, propionate, butanoate, lactate, glycine,maleate, pyruvate, citrate, aconitate, isocitrate, α-ketoglutarate,succinate, fumarate, malate, oxaloacetate, aspartate, glutamate,tris(hydroxymethyl)aminomethane (tromethamine), combinations thereof, orsalts thereof. In another aspect, the formulation has a pH of about 5 toabout 9.5. In another aspect, the formulation has a pH of about 6.5 orabout 8.9. In another aspect, the one or more buffers comprise borate ora salt thereof, glycine or a salt thereof,tris(hydroxymethyl)aminomethane (tromethamine) or a salt thereof, orphosphate or a salt thereof. In another aspect, the one or more bufferscomprise sodium phosphate, glycine, or boric acid. In another aspect,the solvent comprises water. In another aspect, the formulationcomprises about 0.5 M of aqueous anhydrous sodium thiosulfate, about0.01 M of sodium phosphate, pH 6.5, and water. In another aspect, theformulation comprises about 0.5 M of aqueous anhydrous sodiumthiosulfate, about 0.004 M of boric acid, pH 8.6-8.8, and water. Inanother aspect, the formulation comprises about 0.5 M of aqueousanhydrous sodium thiosulfate, about 0.01 M to about 0.05 M of glycine,pH 8.5-8.9, and water. In another aspect, the formulation comprisesabout 0.5 M of aqueous anhydrous sodium thiosulfate, about 0.01 M toabout 0.05 M of tris(hydroxymethyl)aminomethane (tromethamine), pH8.5-8.9, and water.

Another embodiment described herein is a pharmaceutical formulationcomprising about 0.5 M of aqueous anhydrous sodium thiosulfate, about0.01 M of sodium phosphate, pH 6.5, and water made by the methoddescribed herein.

Another embodiment described herein is a pharmaceutical formulationcomprising about 0.5 M of aqueous anhydrous sodium thiosulfate, about0.004 M of boric acid, pH 8.6-8.8, and water made by the methoddescribed herein.

Another embodiment described herein is a pharmaceutical formulationcomprising about 0.5 M of aqueous anhydrous sodium thiosulfate, about0.01 M to about 0.05 M of glycine, pH 8.5-8.9, and water made by themethod described herein.

Another embodiment described herein is a pharmaceutical formulationcomprising about 0.5 M of aqueous anhydrous sodium thiosulfate, about0.01 M to about 0.05 M of tris(hydroxymethyl)aminomethane(tromethamine), pH 8.5-8.9, and water made by the method describedherein.

Another embodiment described herein is a means for preparing apharmaceutical formulation comprising anhydrous sodium thiosulfate, themethod comprising combining anhydrous sodium sulfate with one or morebuffers and a solvent. Another embodiment is a pharmaceuticalformulation prepared by the means described herein.

Another embodiment described herein is a pharmaceutical compositioncomprising an aqueous solution of about 0.2 M to about 2 M of sodiumthiosulfate, about 0.001 M to about 0.05 M of a pharmaceuticallyacceptable buffer, and about 0.005 M to about 0.05 M of apharmaceutically acceptable salt, and a pH of about 5 to about 9.5.

Another embodiment described herein is a kit comprising an aqueoussodium thiosulfate formulation comprising one or more receptaclescomprising aqueous sodium thiosulfate; and documents comprisingprescribing information or instructions for use. In one aspect, the kitfurther comprises one or more syringes, hypodermic needles, andpackaging.

Another embodiment described herein is a kit comprising one or morereceptacles comprising dry or lyophilized sodium thiosulfate; andoptionally: one or more sterile solvents appropriate for reconstitution;a needle and syringe; and documents comprising prescribing informationor instructions for use.

Another embodiment described herein is a pharmaceutical formulationcomprising aqueous anhydrous sodium thiosulfate for injection that isstable and does not precipitate after sterilization and storage. In oneaspect, the formulation comprises about 0.1 M to about 2 M of aqueousanhydrous sodium thiosulfate, 0.001 M to about 0.5 M of sodiumphosphate, glycine, tris(hydroxymethyl)aminomethane (tromethamine), orboric acid.

Another embodiment described herein is a method for preventing orreducing the incidence of by cisplatin (CIS) chemotherapy inducedototoxicity in patients 1 month to <18 years of age with localized,non-metastatic, solid tumors comprising administering sodium thiosulfatefor injection as a 15-minute infusion, 6 hours after the completion ofeach CIS administration, when CIS is infused for no longer than 6 hours.

Also described herein are compositions and methods for reducingototoxicity in patients having received a platinum basedchemotherapeutic. In particular, compositions and intravenousformulations for reducing ototoxicity in pediatric patients aredescribed. Also described are methods for administering the compositionsand formulations. The methods include administering an effective amountof sodium thiosulfate to the patient following administration of theplatinum based chemotherapeutic. As described herein, the administrationof sodium thiosulfate was found to not adversely affect the efficacy ofthe platinum based chemotherapeutic and decreased the incidence andseverity of ototoxicity in pediatric patients. In one aspect, the methodcomprises administering a sodium thiosulfate pharmaceutical compositionas described herein. In another aspect, the pharmaceutical compositioncomprises about 0.5 M of aqueous anhydrous sodium thiosulfate, about0.01 M of sodium phosphate, pH 6.5, and water. In another aspect, theformulation comprises about 0.5 M of aqueous anhydrous sodiumthiosulfate, about 0.004 M of boric acid, pH 8.6-8.8, and water. Inanother aspect, the formulation comprises about 0.5 M of aqueousanhydrous sodium thiosulfate, about 0.01 M to about 0.05 M of glycine,pH 8.5-8.9, and water. In another aspect, the formulation comprisesabout 0.5 M of aqueous anhydrous sodium thiosulfate, about 0.01 M toabout 0.05 M of tris(hydroxymethyl)aminomethane (tromethamine), pH8.5-8.9, and water. Another embodiment is a method of reducingototoxicity in a patient having a cancer and receiving a platinum basedchemotherapeutic comprising administering an effective amount of sodiumthiosulfate to the patient.

Another embodiment is a method of prophylactically treating a patienthaving a cancer and receiving a platinum based chemotherapeutic toreduce a likelihood of the patient incurring ototoxicity comprisingadministering an effective amount of sodium thiosulfate to the patient.In one aspect, the method comprises administering a sodium thiosulfatepharmaceutical composition as described herein. In one aspect, thepharmaceutical composition comprises about 0.5 M of aqueous anhydroussodium thiosulfate, about 0.01 M of sodium phosphate, pH 6.5, and water.In another aspect, the formulation comprises about 0.5 M of aqueousanhydrous sodium thiosulfate, about 0.004 M of boric acid, pH 8.6-8.8,and water. In another aspect, the formulation comprises about 0.5 M ofaqueous anhydrous sodium thiosulfate, about 0.01 M to about 0.05 M ofglycine, pH 8.5-8.9, and water. In another aspect, the formulationcomprises about 0.5 M of aqueous anhydrous sodium thiosulfate, about0.01 M to about 0.05 M of tris(hydroxymethyl)aminomethane(tromethamine), pH 8.5-8.9, and water.

Another embodiment is a method of reducing long term ototoxicity in apatient having a cancer and receiving a platinum based chemotherapeuticcomprising administering an effective amount of sodium thiosulfate tothe patient. In one aspect, the method comprises administering a sodiumthiosulfate pharmaceutical composition as described herein. In anotheraspect, the pharmaceutical composition comprises about 0.5 M of aqueousanhydrous sodium thiosulfate, about 0.01 M of sodium phosphate, pH 6.5,and water. In another aspect, the formulation comprises about 0.5 M ofaqueous anhydrous sodium thiosulfate, about 0.004 M of boric acid, pH8.6-8.8, and water. In another aspect, the formulation comprises about0.5 M of aqueous anhydrous sodium thiosulfate, about 0.01 M to about0.05 M of glycine, pH 8.5-8.9, and water. In another aspect, theformulation comprises about 0.5 M of aqueous anhydrous sodiumthiosulfate, about 0.01 M to about 0.05 M oftris(hydroxymethyl)aminomethane (tromethamine), pH 8.5-8.9, and water.

Another embodiment is a method of reducing a concentration of cisplatinin an aural cavity of a patient having a cancer and receiving a platinumbased chemotherapeutic comprising administering an effective amount ofsodium thiosulfate to the patient, wherein substantially no cisplatin isdetectable in the aural cavity and wherein the patient administered thesodium thiosulfate is less susceptible to incurring ototoxicity from theplatinum based chemotherapeutic.

Another embodiment is a method of inhibiting ototoxic effects associatedwith an administration of platinum-based chemotherapeutic compounds in apatient comprising administering an effective amount of sodiumthiosulfate to the patient.

In some embodiments described herein, the patient carries has singlenucleotide polymorphism in a gene ACYP2 at locus rs1872328. In someembodiments, the patient administered sodium thiosulfate is about 20% toabout 75% less likely to experience ototoxicity than a patient notadministered sodium thiosulfate. In some embodiments, the patientadministered sodium thiosulfate is about 50% less likely to experienceototoxicity than a patient not administered sodium thiosulfate. In someembodiments, ototoxicity comprises hearing loss, dysequilibrium,tinnitus, hearing sensitivity, or combinations thereof.

In some embodiments described herein, the platinum basedchemotherapeutic is selected from cisplatin, carboplatin, oxaliplatin,nedaplatin, triplatin tetranitrate, phenanthriplatin, picoplatin, andsatraplatin. In some embodiments, the platinum based chemotherapeutic iscisplatin.

In some embodiments, the cancer being treated is localized ordisseminated. In some embodiments, the cancer being treated islocalized. In some embodiments, the cancer being treated is selectedfrom a germ cell tumor, hepatoblastoma, medulloblastoma, neuroblastoma,and osteosarcoma. In some embodiments, the cancer being treated ishepatoblastoma. In some embodiments, the cancer being treated is astandard risk cancer, intermediate risk cancer, or high risk cancer. Insome embodiments, the cancer being treated is a standard risk cancer oran intermediate risk cancer. In some embodiments, the cancer beingtreated is standard risk or intermediate risk hepatoblastoma.

In some embodiments, the sodium thiosulfate is administered prior to,concurrently with, or after the administration of the platinum basedchemotherapeutic. In some embodiments, the sodium thiosulfate isadministered about 0.5 hours to about 10 hours after the administrationof the platinum based chemotherapeutic. In some embodiments, the sodiumthiosulfate is administered intravenously. In some embodiments, theeffective amount of sodium thiosulfate is from about 5 g/m² to about 25g/m² per cycle of the platinum based chemotherapeutic. In someembodiments, the patient is being treated with a dose of about 1 mg/kgto about 5 mg/kg or about 10 mg/m² to about 300 mg/m² per cycle of theplatinum based chemotherapeutic. In one aspect, sodium thiosulfatecomprises a pharmaceutical composition as described herein. In anotheraspect, the sodium thiosulfate pharmaceutical composition comprisesabout 0.5 M of aqueous anhydrous sodium thiosulfate, about 0.01 M ofsodium phosphate, pH 6.5, and water. In another aspect, the formulationcomprises about 0.5 M of aqueous anhydrous sodium thiosulfate, about0.004 M of boric acid, pH 8.6-8.8, and water. In another aspect, theformulation comprises about 0.5 M of aqueous anhydrous sodiumthiosulfate, about 0.01 M to about 0.05 M of glycine, pH 8.5-8.9, andwater. In another aspect, the formulation comprises about 0.5 M ofaqueous anhydrous sodium thiosulfate, about 0.01 M to about 0.05 M oftris(hydroxymethyl)aminomethane (tromethamine), pH 8.5-8.9, and water.

In some embodiments described herein, ototoxicity is determined by oneor more criteria comprising: a tinnitus functional index, Brock grading,American Speech-Language-Hearing Association criteria, or InternationalSociety of Pediatric Oncology Boston Ototoxicity Scale. In someembodiments ototoxicity is determined by measuring a hearing loss at oneor more frequencies comprising 500 Hz, 1,000 Hz, 2,000 Hz, 4,000 Hz, or8,000 Hz or a combination of frequencies thereof, wherein a change inhearing is computed relative to baseline measures prior to the patientreceiving a platinum based chemotherapeutic or sodium thiosulfate orboth.

In some embodiments described herein, ototoxicity is determined by oneor more criteria comprising: (a) a reduction in hearing measured by a 20dB loss at a single frequency; (b) a reduction in hearing measured by a10 dB loss at two consecutive frequencies; (c) loss of response at threeconsecutive test frequencies where responses were previously obtained;(d) a reduction in bilateral high-frequency hearing characterized by:(i) a <40 dB hearing loss at all frequencies, which indicates a grade 0or minimal hearing loss; (ii) a ≥40 dB hearing loss at 8,000 Hz only,which indicates a grade 1 or mild hearing loss; (iii) a ≥40 dB hearingloss at 4,000 Hz and above, which indicates a grade 2 or moderatehearing loss; (iv) a ≥40 dB hearing loss at 2,000 Hz and above, whichindicates a grade 3 or marked hearing loss; (v) a ≥40 dB hearing loss at1,000 Hz and above, which indicates a grade 4 or severe hearing loss; or(e) a reduction in hearing characterized by: (i) a ≤20 dB hearing lossat all frequencies, which indicates a grade 0 hearing loss; (ii) a >20dB HL above 4,000 Hz, which indicates a grade 1 hearing loss; (iii)a >20 dB HL at 4,000 Hz and above, which indicates a grade 2 hearingloss; (iv) a >20 dB HL at 2,000 Hz or 3,000 Hz, which indicates a grade3 hearing loss; (v) a >40 dB HL at 2,000 Hz and above, which indicates agrade 1 hearing loss, or (f) an improvement in a tinnitus functionalindex; and wherein a change in hearing is computed relative to baselinemeasures prior to the patient receiving a platinum basedchemotherapeutic or sodium thiosulfate or both. In some embodiments, thepediatric patient administered sodium thiosulfate has a reduction inototoxicity assessed by criterion (d) described above compared to apediatric patient not administered sodium thiosulfate.

In some embodiments described herein, the administration of sodiumthiosulfate to a patient does not lead to increased serum creatinine ora reduction in glomerular filtration rate compared to a patient notadministered sodium thiosulfate. In some embodiments, the administrationof sodium thiosulfate to a patient does not affect relapse free survivalor overall survival compared to a patient not administered sodiumthiosulfate. In some embodiments, the administration of sodiumthiosulfate to a patient does not lead to increased incidence of one ormore adverse events comprising febrile neutropenia, infection,hypomagnesemia, hypernatremia, vomiting, or nausea.

In some embodiments described herein, ototoxicity is measured at a timeof at least 4 weeks following the administration of the platinum basedchemotherapeutic and sodium thiosulfate to a patient. In one aspect, thesodium thiosulfate comprises a pharmaceutical composition as describedherein. In another aspect, the sodium thiosulfate pharmaceuticalcomposition comprises about 0.5 M of aqueous anhydrous sodiumthiosulfate, about 0.01 M of sodium phosphate, pH 6.5, and water. Inanother aspect, the formulation comprises about 0.5 M of aqueousanhydrous sodium thiosulfate, about 0.004 M of boric acid, pH 8.6-8.8,and water. In another aspect, the formulation comprises about 0.5 M ofaqueous anhydrous sodium thiosulfate, about 0.01 M to about 0.05 M ofglycine, pH 8.5-8.9, and water. In another aspect, the formulationcomprises about 0.5 M of aqueous anhydrous sodium thiosulfate, about0.01 M to about 0.05 M of tris(hydroxymethyl)aminomethane(tromethamine), pH 8.5-8.9, and water.

In some embodiments described herein, the patient is a pediatricpatient. In some embodiments described herein, the pediatric patient is1 week of age to 18 years of age. In some embodiments, the pediatricpatient is about 12 years of age or less. In some embodiments, thepediatric patient is about 5 years of age or less. In some embodiments,the pediatric patient is about 2 years of age or less. In someembodiments, the pediatric patient is about 1 year of age or less.

Another embodiment is a dosing regimen for treating hepatoblastoma in apediatric patient comprising: (a) administering a dose of about 1 mg/kgto about 5 mg/kg or about 10 mg/m² to about 300 mg/m² per cycle ofcisplatin; (b) administering about 5 g/m² to about 25 g/m² of sodiumthiosulfate per cycle of the cisplatin, wherein the sodium thiosulfateis administered from about 2 hours to about 6 hours after theadministration of the cisplatin; and wherein the dosing regimen achievesa reduction in ototoxicity when dosed to a pediatric patient compared toa dosing regimen not including the sodium thiosulfate, which is dosed toa pediatric patient, wherein ototoxicity is determined by one or morecriteria selected from: (a) a reduction in hearing measured by a 20 dBloss at a single frequency; (b) a reduction in hearing measured by a 10dB loss at two consecutive frequencies; (c) loss of response at threeconsecutive test frequencies where responses were previously obtained;(d) a reduction in bilateral high-frequency hearing characterized by thecriteria: (i) a <40 dB hearing loss at all frequencies, which indicatesa grade 0 or minimal hearing loss; (ii) a ≥40 dB hearing loss at 8,000Hz only, which indicates a grade 1 or mild hearing loss; (iii) a ≥40 dBhearing loss at 4,000 Hz and above, which indicates a grade 2 ormoderate hearing loss; (iv) a ≥40 dB hearing loss at 2,000 Hz and above,which indicates a grade 3 or marked hearing loss; (v) a ≥40 dB hearingloss at 1,000 Hz and above, which indicates a grade 4 or severe hearingloss; or (e) a reduction in hearing characterized by the criteria: (i) a≤20 dB hearing loss at all frequencies, which indicates a grade 0hearing loss; (ii) a >20 dB HL above 4,000 Hz, which indicates a grade 1hearing loss; (iii) a >20 dB HL at 4,000 Hz and above, which indicates agrade 2 hearing loss; (iv) a >20 dB HL at 2,000 Hz or 3,000 Hz, whichindicates a grade 3 hearing loss; (v) a >40 dB HL at 2,000 Hz and above,which indicates a grade 1 hearing loss; wherein a change in hearing iscomputed relative to baseline measures prior to the patient receiving aplatinum based chemotherapeutic or sodium thiosulfate or both. In oneaspect, the regimen comprises administering a sodium thiosulfatepharmaceutical composition as described herein. In another aspect, thepharmaceutical composition comprises about 0.5 M of aqueous anhydroussodium thiosulfate, about 0.01 M of sodium phosphate, pH 6.5, and water.In another aspect, the formulation comprises about 0.5 M of aqueousanhydrous sodium thiosulfate, about 0.004 M of boric acid, pH 8.6-8.8,and water. In another aspect, the formulation comprises about 0.5 M ofaqueous anhydrous sodium thiosulfate, about 0.01 M to about 0.05 M ofglycine, pH 8.5-8.9, and water. In another aspect, the formulationcomprises about 0.5 M of aqueous anhydrous sodium thiosulfate, about0.01 M to about 0.05 M of tris(hydroxymethyl)aminomethane(tromethamine), pH 8.5-8.9, and water.

Another embodiment is method of reducing ototoxicity in a pediatricpatient of about 12 years of age and under having a standard risk or anintermediate risk hepatoblastoma and receiving a dose of about 1 mg/kgto about 5 mg/kg or about 10 mg/m² to about 300 mg/m² per cycle ofcisplatin, the method comprising administering about 5 g/m² to about 25g/m² of sodium thiosulfate per cycle of the cisplatin about six hoursafter the administration of the cisplatin, wherein ototoxicity isdetermined by one or more criteria selected from: (a) a reduction inhearing measured by a 20 dB loss at a single frequency; (b) a reductionin hearing measured by a 10 dB loss at two consecutive frequencies; (c)loss of response at three consecutive test frequencies where responseswere previously obtained; (d) a reduction in bilateral high-frequencyhearing characterized by the criteria: (i) a <40 dB hearing loss at allfrequencies, which indicates a grade 0 or minimal hearing loss; (ii) a≥40 dB hearing loss at 8,000 Hz only, which indicates a grade 1 or mildhearing loss; (iii) a ≥40 dB hearing loss at 4,000 Hz and above, whichindicates a grade 2 or moderate hearing loss; (iv) a ≥40 dB hearing lossat 2,000 Hz and above, which indicates a grade 3 or marked hearing loss;(v) a ≥40 dB hearing loss at 1,000 Hz and above, which indicates a grade4 or severe hearing loss; or (e) a reduction in hearing characterized bythe criteria: (i) a ≤20 dB hearing loss at all frequencies, whichindicates a grade 0 hearing loss; (ii) a >20 dB HL above 4,000 Hz, whichindicates a grade 1 hearing loss; (iii) a >20 dB HL at 4,000 Hz andabove, which indicates a grade 2 hearing loss; (iv) a >20 dB HL at 2,000Hz or 3,000 Hz, which indicates a grade 3 hearing loss; (v) a >40 dB HLat 2,000 Hz and above, which indicates a grade 1 hearing loss; wherein achange in hearing is computed relative to baseline measures prior to thepatient receiving a platinum based chemotherapeutic or sodiumthiosulfate or both; and wherein the administration of sodiumthiosulfate does not substantively affect relapse free survival oroverall survival compared to a pediatric patient not administered sodiumthiosulfate; and wherein the administration of sodium thiosulfate doesnot lead to substantively increased incidence of one or more adverseevents comprising febrile neutropenia, infection, hypomagnesemia,hypernatremia, vomiting, or nausea. In one aspect, the method comprisesadministering a sodium thiosulfate pharmaceutical composition asdescribed herein. In another aspect, the pharmaceutical compositioncomprises about 0.5 M of aqueous anhydrous sodium thiosulfate, about0.01 M of sodium phosphate, pH 6.5, and water. In another aspect, theformulation comprises about 0.5 M of aqueous anhydrous sodiumthiosulfate, about 0.004 M of boric acid, pH 8.6-8.8, and water. Inanother aspect, the formulation comprises about 0.5 M of aqueousanhydrous sodium thiosulfate, about 0.01 M to about 0.05 M of glycine,pH 8.5-8.9, and water. In another aspect, the formulation comprisesabout 0.5 M of aqueous anhydrous sodium thiosulfate, about 0.01 M toabout 0.05 M of tris(hydroxymethyl)aminomethane (tromethamine), pH8.5-8.9, and water.

One or more embodiments or aspects may be incorporated in a differentembodiment or aspect although not specifically described. That is, allembodiments and aspects can be combined in any way or combination.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 shows a scheme for synthesizing anhydrous sodium thiosulfate.

FIG. 2A shows X-ray powder diffraction pattern for anhydrous sodiumthiosulfate synthesized as described herein. Peaks are shown in Table 5.

FIG. 2B shows X-ray powder diffraction pattern for sodium thiosulfatepentahydrate. Peaks are shown in Table 6.

FIG. 3 shows overlayed X-ray powder diffraction patterns for sodiumthiosulfate pentahydrate (top pattern) and anhydrous sodium thiosulfatesynthesized as described herein (bottom pattern).

FIG. 4A shows overlayed differential scanning calorimetry (DSC) andthermogravimetric analysis (TGA) for anhydrous sodium thiosulfatesynthesized as described herein. The DSC thermogram shows a single,sharp endotherm with an onset of 331.4° C. In the thermogravimetricanalysis, there is negligible weight loss from 25° C. to 162° C.; from162° C. to 309° C. there is a weight loss of 14.81% followed by theonset of decomposition at 436° C.

FIG. 4B shows the dynamic vapor sorption (DVS) isotherm for anhydroussodium thiosulfate synthesized as described herein. The DVS isothermshowed a minimal weight change upon equilibration to 0% relativehumidity. Upon sorption, the exhibits a weight gain of 165%. Hysteresiswas observed upon desorption, with a weight loss of 51%.

FIG. 5 shows a plot of cisplatin concentration versus time for cisplatin(control) or cisplatin combined with sodium thiosulfate at ratios ofsodium thiosulfate:cisplatin of 5:1, 6:1, or 10:1. Data are shown inTable 7.

FIG. 6 shows a scheme for preparing a pharmaceutical formulationcomprising anhydrous sodium thiosulfate.

DETAILED DESCRIPTION

The terms “active ingredient”, “active pharmaceutical ingredient,” or“API” as used herein refer to a pharmaceutical agent, active ingredient,compound, or substance, compositions, or mixtures thereof, that providea pharmacological, often beneficial, effect.

The term “dose” as used herein denotes any form of the active ingredientformulation that contains an amount sufficient to produce a therapeuticeffect with a single administration.

The term “dosage” as used herein refers to the administering of aspecific amount, number, and frequency of doses over a specified periodof time, typically 1 day.

The terms “active pharmaceutical ingredient load” or “drug load” as usedherein refers to the quantity (mass) of the active pharmaceuticalingredient comprised in a single soft capsule fill.

The terms “formulation” or “pharmaceutical composition” as used hereinrefers to the drug in combination with pharmaceutically acceptableexcipients.

The term mean “particle size distribution” (PSD) as used herein refersto the mean particle size from a statistical distribution of a range ofparticle sizes as described herein. The distribution may be a Gaussian,normal distribution, or a non-normal distribution.

The terms such as “d90,” “d50,” and “d10” refer to the percentage (e.g.,90%, 50%, or 10%, respectively) of particle sizes that are less than aspecified size, range, or distribution. For example, “d90≤100 μm” asmeans that 90% of the particle sizes within a distribution of particlesare less than or equal to 100 μm.

As used herein, the term “patient” refers to any subject includingmammals and humans. The patient may have a disease or suspected ofhaving a disease and as such is being treated with a drug. In someinstances, the patient is a mammal, such as a human, non-human primate,dog, cat, horse, cow, goat, pig, rabbit, rat, mouse, or a prematureneonate, neonate, infant, juvenile, adolescent, or adult thereof. Insome instances, the term “patient,” as used herein, refers to a human(e.g., a man, a woman, or a child). In some instances, the term“patient,” as used herein, refers to laboratory animal of an animalmodel study. The patient or subject may be of any age, sex, orcombination thereof. In some embodiments described herein, the patientis treated with a platinum based chemotherapeutic, such as cisplatin,followed by administration of sodium thiosulfate or a formulationthereof.

The term “pediatric patient” refers to a pediatric mammal or human. Insome instances, the patient is a mammal, such as a human, non-humanprimate, dog, cat, horse, cow, goat, pig, rabbit, rat, mouse, or apremature neonate, neonate, infant, toddler, child, adolescent,juvenile, or teenager thereof. The pediatric patient may be of anyethnicity or sex. The pediatric patient may be of any age, which wouldbe understood to the person of skill in the art to be a pediatricpatient in medicine and in veterinary medicine. For example, a humanpediatric patient may be a neonate up to 18 years of age. A newbornpediatric is understood to be birth to 1 month of age; an infant is 1month to 2 years of age; a child is 2 years to 12 years of age; and anadolescent is 12 to 18 years of age. In some countries, a pediatricpatient includes those up to the age of 21 years of age. The pediatricpatient may have a disease or suspected of having a disease and as suchis being treated with a drug. In some embodiments as described furtherherein, the pediatric patient is treated with a platinum basedchemotherapeutic such as cisplatin.

The term “ototoxicity” refers to any type of toxicity that affects theear. The toxicity may be to the cochlea (e.g., cochleotoxicity),cochlear hair cells, the auditory nerve, or the vestibular system or anyof these systems found in the ear or any of these systems incombination. The toxicity can manifest as hearing loss, sensorineuralhearing loss, dysequilibrium, tinnitus, or hearing sensitivity orcombinations thereof. When referring to hearing loss, the amount oftoxicity causing the hearing loss can be mild, moderate, severe,profound, or total resulting in complete deafness. Alternatively, thehearing loss may present at specific frequencies including both high andlow frequencies and all iterations of frequencies normal to mammalianhearing. The toxicity can be unilateral, bilateral, bilateral symmetric,or bilateral asymmetric with one ear being affected more than the otheris.

The terms “biological sample” or “sample” as used herein refers to asample obtained or derived from a patient. By way of example, abiological sample comprises a material selected from the groupconsisting of body fluids, blood, whole blood, plasma, serum, mucussecretions, saliva, cerebrospinal fluid (CSF), bronchoalveolar lavagefluid (BALF), urine, fluids of the eye (e.g., vitreous fluid, aqueoushumor), lymph fluid, lymph node tissue, spleen tissue, bone marrow, andfluid from the auditory cavity.

The term “treating” refers to administering a therapy in an amount,manner, or mode effective (e.g., a therapeutic effect) to improve acondition, symptom, disorder, or parameter associated with a disorder,or a likelihood thereof.

The term “prophylaxis” refers to preventing or reducing the progressionof a disorder, either to a statistically significant degree or to adegree detectable to one skilled in the art.

The terms “essentially” or “substantially” as used herein mean to agreat or significant extent, but not completely.

The term “about” as used herein refers to any values, including bothintegers and fractional components that are within a variation of up to±10% of the value modified by the term “about.”

As described herein, it was found that sodium thiosulfate (STS) reducesototoxicity in pediatric patients being treated with platinum basedchemotherapeutics. It was surprisingly found that children under the ageof 12 have higher rates of ototoxicity and children under the age of 5are even more at risk. It was further found that the administration ofSTS after a platinum based chemotherapeutic (e.g., cisplatin)significantly reduced ototoxicity in these pediatric patients. Inparticular, it was discovered that STS could reduce the severity ofototoxicity, such as Brock grade 2 and 3 ototoxicities. Further, it wasidentified that the total amount of cisplatin exposure or cumulativedose did not interfere with STS mediated otoprotection. In addition, itwas discovered that STS is highly suitable as an otoprotective drug whenused in conjunction with local (non-disseminated) cancers. Reference ismade to International Patent Application Publication No. WO 2019/108592,which is a continuation of U.S. patent application Ser. No. 15/826,243,filed on Nov. 29, 2017, both of which are incorporated by referenceherein in their entirety.

Sodium thiosulfate (also known as sodium hyposulfite) is a water-solublethiol compound with the formula Na₂S₂O₃. The compound is available asanhydrous and crystalline forms; the pentahydrate crystalline form isthe most common hydrate form. STS is commercially available as anestablished antidote for acute cyanide poisoning. STS is a reducingagent and has been used in oncology for preventing cisplatinnephrotoxicity, carboplatin ototoxicity, and as an antidote forextravasation of various chemotherapy agents. The mechanism by whichsodium thiosulfate reduces the nephrotoxicity caused by cisplatin andthe ototoxicity by carboplatin is not understood. Proposed mechanisms ofaction involve its thiol group, which allow it to act as a free radicalscavenger and/or by covalent binding and inactivating the platinumcompound. Sodium thiosulfate reacts irreversibly with cisplatin to formPt(S₂O₃)₄ when the drugs are given simultaneously, successively, ornearly contemporaneously. It is also believed that sodium thiosulfateprotects against nephrotoxicity by reducing delivery of cisplatin to thekidneys and by neutralizing cisplatin in the kidneys where sodiumthiosulfate is highly concentrated. Following IV administration, sodiumthiosulfate is distributed throughout the extracellular fluid. Somesodium thiosulfate is converted to sulfate in the liver. Up to 95% isexcreted in the urine unmodified. The biological half-life is 0.65 hours(range: dependent on dose 16.5-182 minutes). When given intravenously,STS is rapidly excreted by the kidney.

While not being bound by any theory, it is believed that the biologicaleffects of STS in preventing cisplatin-induced ototoxicity includebinding to the electrophilic platinum molecules, the scavenging ofreactive oxygen species, and the increased concentration in cochlearendolymph. Thus, a single effective dosage scavenges any residualplatinum chemotherapeutic so that it cannot accumulate and damage thecochlear hair. The results from two phase III clinical trialsdemonstrated that the efficacy of cisplatin based chemotherapeutics inpediatric patients was not affected when STS was administered.

In addition, STS does not adversely affect the efficacy of several othernon-platinum based chemotherapeutics such as doxorubicin and etoposide.In vitro studies of small cell lung cancer cell cultures showed noreduction of cytotoxicity for etoposide after the immediate or delayedaddition of STS followed by incubation for 72 hours. Similar studiesshowed no reduction of anti-tumor activity by STS for doxorubicin,carmustine (BCNU), paclitaxel, or methotrexate. Owing to its ability toscavenge free platinum containing compounds, STS was extensively testedin the clinic, as further described herein, and found to be a highlyeffective otoprotective compound for pediatric patients.

One embodiment described herein is sodium thiosulfate. Anotherembodiment described herein is anhydrous sodium thiosulfate. In anotherembodiment, the sodium thiosulfate does not comprise a hydrate. Inanother embodiment, the sodium thiosulfate does not comprises sodiumthiosulfate pentahydrate. In one embodiment, the sodium thiosulfatecomprises crystalline anhydrous sodium thiosulfate. In one embodiment,the sodium thiosulfate comprises amorphous anhydrous sodium thiosulfate.In another embodiment, the sodium thiosulfate comprises aqueousanhydrous sodium thiosulfate.

One embodiment is anhydrous sodium thiosulfate synthesized as describedherein.

Another embodiment described herein is a method for synthesizinganhydrous sodium thiosulfate. In one aspect, sodium thiosulfate issynthesized by reacting aqueous sodium sulfite with sulfur in thepresence of a detergent, such as cetylpyridinium chloride (CPC). In oneembodiment, about 1.0 mole equivalent of sodium sulfite is reacted with1.1 mole equivalent of sulfur and 0.00013 mole equivalents ofcetylpyridinium chloride. In one aspect, the reaction is conducted atelevated temperature. In another aspect, the reaction is conducted atabout 75° C. to about 100° C. for a period of about 5 min to 5 hours. Inanother aspect, the reaction is conducted at about 90° C. for about 5min to 3 hours. In one aspect, the reaction is heated to about 90° C.and the reaction is completed upon reaching about 90° C. In anotheraspect, the reaction is cooled following the reaction. In one aspect,the reaction is cooled to room temperature. In another aspect, thereaction is cooled to <2° C. In another aspect, the sodium thiosulfateis washed using a washing solvent. In another aspect, the sodiumthiosulfate is washed using acetone. In another aspect, the sodiumthiosulfate is washed multiple times. In another aspect, the sodiumthiosulfate is washed one time. In another aspect, the sodiumthiosulfate is dehydrated by heating and/or filtering. In anotheraspect, the sodium thiosulfate is dehydrated using a dehydratingsolvent. In one aspect, the dehydrating solvent is an alcohol. Inanother aspect, the dehydrating solvent is methanol. In another aspect,the dehydrating solvent is methanol that has been heated to between 30°C. and 80° C. In another aspect, the sodium thiosulfate is dehydratedmultiple times. In another aspect, the sodium thiosulfate is dehydratedone time.

In one embodiment, the anhydrous sodium thiosulfate is milled ormicronized to a defined particle size. In one embodiment, the anhydroussodium thiosulfate comprises a particle size range of about 1 μm toabout 500 μm, including all integers and fractions within the specifiedrange. In one aspect, the micronized anhydrous sodium thiosulfateparticles have a particle size of about 1 μm to about 100 μm. In oneaspect, the micronized anhydrous sodium thiosulfate particles have aparticle size of about 5 μm to about 50 μm. In another aspect, the solidparticles of anhydrous sodium thiosulfate comprise a distribution ofparticle sizes, comprising particles of any of the foregoing particlesizes.

In another embodiment, the anhydrous sodium thiosulfate particles havemean particle size distributions (PSD) ranging from about 5 μm to about300 μm, including all integers and fractions within the specified range.In one aspect, the solid particles of anhydrous sodium thiosulfatecomprise mean particle size distributions of about 5 μm, about 10 μm,about 15 μm, about 20 μm, 25 μm, about 30 μm, about 40 μm, about 50 μm,about 60 μm, about 70 μm, about 80 μm, about 90 μm, about 100 μm, about120 μm, about 140 μm, about 160 μm, about 180 μm, about 190 μm, about200 μm, about 220 μm, about 240 μm, about 260 μm, about 280 μm, or about300 μm.

In one embodiment, the solid particles of anhydrous sodium thiosulfatehave a mean particle size distribution d50 of about 5 μm to about 100μm. In one embodiment, the solid particles of anhydrous sodiumthiosulfate have a mean particle size distribution d50 of about 5 μm toabout 50 μm. In one aspect, the solid particles of anhydrous sodiumthiosulfate have a mean particle size distribution d50 of about 10 μm toabout 25 μm.

In another embodiment, the anhydrous sodium thiosulfate particles have aparticle size distribution with a d90 of less than or equal to about 100μm. In one aspect, the particle size distribution of solid particles ofanhydrous sodium thiosulfate have a d90 of ≤ to about 50 μm. In oneaspect, the solid particles of anhydrous sodium thiosulfate have aparticle size distribution with a d90 of ≤ about 25 μm (d90≤25 μm).

In another embodiment, the solid particles of anhydrous sodiumthiosulfate comprise multiple distributions of particle sizes. In oneaspect, the solid particles of anhydrous sodium thiosulfate may comprisea plurality of independently combined mean particle size distributions,wherein each independent mean particle size distribution ranges fromabout 5 μm to about 100 μm, including all integers and fractions withinthe specified range. In another aspect, the solid particles of anhydroussodium thiosulfate may comprise a plurality of independently combinedmean particle size distributions, wherein each independent mean particlesize distribution ranges from about 5 μm to about 50 μm, including allintegers and fractions within the specified range. In another aspect,the solid particles of anhydrous sodium thiosulfate comprise acombination of independently combined mean particle size distributionsof about 10 μm to about 30 μm including all integers and fractionswithin the specified range. Any of the foregoing particle sizedistributions may be combined to provide the desired size distributionrange.

The foregoing sizes of anhydrous sodium thiosulfate particles may bedetermined using standard techniques known to one of ordinary skill inthe art. The exemplary techniques that can be used for measuring thesize of anhydrous sodium thiosulfate particles may include laserdiffraction analysis, light scattering (e.g., dynamic light scattering),microscopic particle image analysis, elutriation, or aerosol massspectrometry. The sample of anhydrous sodium thiosulfate particles maybe measured as a dry sample or a wet sample. Any commercially availableinstrument for measuring particle sizes may be used, includinginstruments from Cilas; Brookhaven Instruments Corporation; MalvernInstruments; Horiba Scientific; or Wyatt following the recommendedoperating procedures according to the manufacturer's instructions.

The measured particle sizes using the techniques described herein may beexpressed as a derived diameter with a normal distribution or non-normaldistribution with a mean, median (e.g., mass median diameter), and modeof particle diameter sizes. The particle size distribution may beexpressed as a diameter number distribution, a surface areadistribution, or a particle volume distribution. The mean of theparticle size distribution may be calculated and expressed in variousways, such as the volume mean diameter (D[4,3] or d₄₃), mean surfacearea diameter (D[3,2] or d₃₂) or the mean number particle diameter(D[1,0] or d₁₀). Because the particle size distribution values varydepending on the measurement methodology and how the distribution isexpressed, the comparison of different mean particle size distributionsmust be calculated by the same methodology in order to yield an accuratecomparison. For example, a sample with a measured and calculated volumemean diameter must be compared with a second sample having a measuredand calculated volume mean diameter, ideally measured using the samemeasuring instrument under the same conditions. Thus, the specificparticle size distributions described herein are not intended to belimited to any one type of method for measuring or calculating aparticle size distribution (e.g., a diameter number distribution, asurface area distribution, or a particle volume distribution), butrather indicate particle size values and distributions thereof for eachmethod of measuring particle sizes described herein.

Another embodiment described herein is anhydrous sodium thiosulfate madeby the methods described herein. Another embodiment is a means forpreparing anhydrous sodium thiosulfate.

Another embodiment described herein is anhydrous sodium thiosulfatecharacterized by an X-ray powder diffraction (XRPD) pattern comprisingat least four peaks at 10.52, 15.13, 17.71, 19.70, 21.09, 21.49, 21.84,27.40, 28.96, 30.46, 31.81, 32.52, 33.15, 37.40, or 38.16 degrees 2theta (2 θ)±0.2, when the XRPD is collected from about 2 to about 40degrees 2 θ using copper Kα radiation. In one embodiment, the anhydroussodium thiosulfate characterized by an X-ray powder diffraction (XRPD)pattern comprising at least four peaks selected from 10.52, 15.13,19.70, 21.49, 21.84, 28.96, 30.46, 33.15, 37.40, or 38.16 degrees 2theta (2 θ)±0.2, when the XRPD is collected from about 2 to about 40degrees 2 θ using copper Kα radiation. In one embodiment, the anhydroussodium thiosulfate is characterized by an XRPD pattern substantiallysimilar to the XRPD pattern of FIG. 2A. In another embodiment, theanhydrous sodium thiosulfate is characterized by an X-ray powderdiffraction (XRPD) pattern comprising at least 1, at least 2, at least3, at least 4 at least 5, at least 6 at least 7, at least 8, at least 9,or at least 10 of the peaks shown in Table 5.

Another embodiment described herein is anhydrous sodium thiosulfatecomprising: no greater than 0.1 μg/g of cadmium; no greater than 0.25μg/g lead; no greater than 0.75 μg/g arsenic; no greater than 0.15 μg/gmercury; no greater than 0.25 μg/g cobalt; no greater than 0.5 μg/gvanadium; no greater than 1.0 μg/g nickel; no greater than 12.5 μg/glithium; no greater than 4.5 μg/g antimony; no greater than 15.0 μg/gcopper; no greater than 1500 ppm methanol; no greater than 3% (w/w)water; and no greater than 1.5% (w/w) of total impurities.

Another embodiment described herein is anhydrous sodium thiosulfatecomprising essentially no sodium thiosulfate pentahydrate. In oneaspect, anhydrous sodium thiosulfate comprises less than 1%, less than0.5%, less than 0.2%, less than 0.1%, less than 0.05%, or less than0.001% sodium thiosulfate pentahydrate.

Another embodiment described herein is an assay for measuring theconcentration of cisplatin. In one aspect, the assay comprises measuringthe cisplatin concentration using HPLC and UV detection and comparingthe retention time and peak area to a standard curve of cisplatinconcentration assayed under similar conditions. Another embodimentdescribed herein is a means for determining a cisplatin concentration asdescribed herein.

Another embodiment described herein is an assay for determining thecisplatin binding capacity of a composition of sodium thiosulfate. Thesodium thiosulfate composition may be sodium thiosulfate pentahydrate,anhydrous sodium thiosulfate, aqueous anhydrous sodium thiosulfate, or apharmaceutical composition of sodium thiosulfate. The assay comprisescombining various concentrations of sodium thiosulfate with aconcentration of cisplatin and then measuring the apparent diminution ofcisplatin concentration using HPLC and UV detection over a time course.In one aspect, the mole ratio of sodium thiosulfate to cisplatin is10:1, 7:1, 6:1, 5:1, 3:1, 2:1, or 1:1. In one aspect, the mole ratio ofsodium thiosulfate to cisplatin is 10:1, 6:1, or 5:1. In one aspect, theapparent diminution of cisplatin concentration owing to binding bysodium thiosulfate is linear over time. In another aspect, the cisplatinconcentration is measured about 5 mins after mixing with sodiumthiosulfate and is measured every 10, 20, 30, or 60 min for a period of0.5, 1, 2, 3, 4, 5, or 6 hours. In one aspect, the cisplatinconcentration is determined about 5 mins after mixing with sodiumthiosulfate and is measured every 30 min for a period of 2 hours. In oneaspect, a mixed mode C-18 chromatography column is used in the assay,which has both hydrophobic interaction and ion exchange capabilities. Inanother aspect, the HPLC run time for the assay is about 2 min, about 5min, about 7.5 min, about 10 min or about 15 min. In one aspect, theHPLC run time is about 5 min or about 10 min. In another aspect,cisplatin elutes from the HPLC under the assay conditions after about1.5 min to about 2.5 min. In one aspect, cisplatin elutes from the HPLCunder the assay conditions after about 2 min. In another aspect, sodiumthiosulfate elutes from the HPLC under the assay conditions after about5 min to about 7.0 min. In one aspect, cisplatin elutes from the HPLCunder the assay conditions after about 6 min.

Another embodiment described herein is a means for determining a sodiumthiosulfate binding capacity for cisplatin as described herein.

Without being bound by any theory, factors that affect cisplatin bindingby sodium thiosulfate in the assay described herein include thetemperature, relative concentration of sodium thiosulfate, and the timeelapsed between mixing cisplatin with sodium thiosulfate and HPLCmeasurement. An HPLC autosampler allows tight temperature control andfacilitates sample preparation and analysis. In addition, this methodprovides the change in concentration of cisplatin over time as opposedto at a single time point. This method can be used to determine areaction rate under given conditions or a half-life for comparisonsbetween different samples of sodium thiosulfate.

Another embodiment described herein is an assay for measuring thebinding capacity of sodium thiosulfate for cisplatin based on theapparent diminution of cisplatin concentration after combining variousmole ratios of cisplatin and sodium thiosulfate, the method comprising:mixing various mole ratios of sodium thiosulfate with predeterminedquantities of cisplatin; incubating the mixture for a period of time;and analyzing the concentration of cisplatin. In one aspect, the moleratio of sodium thiosulfate to cisplatin is 10:1 to 1:1. In one aspect,the mole ratio of sodium thiosulfate to cisplatin is 10:1, 7:1, 6:1,5:1, 3:1, 2:1, or 1:1. In one aspect, the mixture is incubated at about25° C. for about 5 min, about 35 min, about 65 min, about 95 min, andabout 125 min and analyzed. In another aspect, the concentration isanalyzed using HPLC with a mixed mode C-18 chromatography column at acolumn temperature of 35° C., flow rate of 400 μL/min, and UV detectionat 220 nm. In one aspect, the HPLC method comprises a step gradient of100% Buffer A (0.5 mM ammonium formate in 9:1 water:acetonitrile, pH 4)for 3 min; then 90% Buffer A and 10% Buffer B (200 mM ammonium formatein 7:3 water:acetonitrile, pH 4) for 3.5 min; then 100% Buffer A for 4.5min.

Another embodiment described herein is a pharmaceutical composition orformulation comprising sodium thiosulfate. In one aspect, the sodiumthiosulfate comprises anhydrous sodium thiosulfate. The formulation issuitable for administration through any conventional route includingintravenously, subcutaneously, intramuscularly, intraperitoneally,intrathecally, orally, rectally, vaginally, or a combination thereof. Inone aspect, the formulation is administered intravenously.

In one embodiment, the pharmaceutical compositions described hereinprovide a composition of sodium thiosulfate for administration to asubject. The sodium thiosulfate can be administered, for example, to asubject, or a subject in need thereof.

Another embodiment described herein is a pharmaceutical compositioncomprising sodium thiosulfate. In one aspect, the composition comprisessodium thiosulfate and one or more pharmaceutically acceptableexcipients. In another aspect, the composition comprises sodiumthiosulfate and a buffer. In another aspect, the composition comprisesanhydrous sodium thiosulfate and a buffer. In one aspect, thecomposition comprises a liquid formulation of anhydrous sodiumthiosulfate and a buffer. In another aspect, the composition is a dry orlyophilized composition comprising sodium thiosulfate and one or morebuffers that is reconstituted with sterile water for injection prior toadministration. In another aspect, the composition comprises aqueousanhydrous sodium thiosulfate, one or more buffers, and a solvent. Asused herein, “aqueous anhydrous sodium thiosulfate” refers to anhydroussodium thiosulfate that has been solubilized in an aqueous solvent. Inanother aspect, the composition comprises aqueous anhydrous sodiumthiosulfate, one or more buffers, one or more agents to adjust the pH,and a solvent. In another aspect, the composition comprises aqueousanhydrous sodium thiosulfate, one or more buffers, one or more agents toadjust the pH, a solvent, and one or more preservatives, physiologicalsalts, carriers, or pharmaceutically acceptable excipients. In oneembodiment, the pharmaceutical formulation comprises that shown in Table1.

TABLE 1 Exemplary Sodium Thiosulfate Formulation IngredientConcentration/Amount Sodium thiosulfate 0.1-2M Buffer(s) 0.001-0.5M   pH adjusting agent(s): As needed to adjust to pH 5-8 e.g., NaOH, HClPreservatives, Optional; up to 25% by mass physiological salts,carriers, pharmaceutically acceptable excipients Solvent (e.g., sterilequantum sufficit (q.s.) water for injection)

In another embodiment, the formulation comprises aqueous anhydroussodium thiosulfate and water. In another aspect, the formulationcomprises aqueous anhydrous sodium thiosulfate, water, a buffer, and oneor more pH-adjusting agents. In another aspect, the formulationcomprises aqueous anhydrous sodium thiosulfate, water, phosphate buffer,and one or more pH-adjusting agents to bring the pH to about 6.5. Inanother aspect, the formulation comprises aqueous anhydrous sodiumthiosulfate, water, borate buffer, and one or more pH-adjusting agentsto bring the pH to about 8.5-8.8. In another aspect, the formulationcomprises aqueous anhydrous sodium thiosulfate, water, glycine, and oneor more pH-adjusting agents to bring the pH to about 8.5-8.9. In anotheraspect, the formulation comprises aqueous anhydrous sodium thiosulfate,water, tris(hydroxymethyl)aminomethane (tromethamine) buffer, and one ormore pH-adjusting agents to bring the pH to about 8.5-8.9. In oneembodiment, the pharmaceutical formulation comprises one of theformulations shown in Table 2. The following formulations are exemplaryand the identity and concentration of the buffers can be adjusted overthe range of about 0.001 M to about 0.5 M and the mg/mL and percentweight adjusted accordingly.

TABLE 2 Exemplary Sodium Thiosulfate Formulations (solution) ComponentMass/Volume Molarity Percent Weight Sodium thiosulfate, anhydrous 80.0mg/mL 0.5M 8% Sodium phosphate, pH 6.5 1.4 mg/mL 0.01M 0.12%   Sodiumthiosulfate, anhydrous 80.0 mg/mL 0.5M 8% Boric acid, pH 8.6-8.8 0.25mg/mL 0.004M 0.023%    Sodium thiosulfate, anhydrous 80.0 mg/mL 0.5M 8%Glycine, pH 8.5-8.9 0.75 mg/mL 0.01M 0.069%    Sodium thiosulfate,anhydrous 80.0 mg/mL 0.5M 8% Tris(hydroxymethyl)aminomethane 1.21 mg/mL0.01M 0.11%   (tromethamine), pH 8.5-8.9

In one embodiment, the formulation comprises about 0.1 M; about 0.2 M;about 0.3 M; about 0.4 M; about 0.5 M; about 0.6 M; about 0.7 M; about0.8 M; about 0.9 M; about 1.0 M; about 1.1 M; about 1.2 M; about 1.3 M;about 1.4 M; about 1.5 M; about 1.6 M; about 1.7 M; about 1.8 M; about1.9 M; or about 2.0 M of aqueous anhydrous sodium thiosulfate.

In another embodiment, the formulation comprises about 0.1 M to about2.0 M; about 0.1 M to about 0.5 M; about 0.1 M to about 0.6 M; about 0.1M to about 0.7 M; about 0.1 M to about 0.8 M; about 0.1 M to about 1.0M; about 0.2 M to about 0.5 M; about 0.2 M to about 0.6 M; about 0.2 Mto about 0.7 M; about 0.2 M to about 0.8 M; about 0.2 M to about 1.0 M;about 0.3 M to about 0.5 M; about 0.3 M to about 0.6 M; about 0.3 M toabout 0.7 M; about 0.3 M to about 0.8 M; about 0.3 M to about 1.0 M;about 0.4 M to about 0.5 M; about 0.4 M to about 0.6 M; about 0.4 M toabout 0.7 M; about 0.4 M to about 0.8 M; about 0.4 M to about 1.0 M;about 0.5 M to about 0.6 M; about 0.5 M to about 0.7 M; about 0.5 M toabout 0.8 M; about 0.5 M to about 1.0 M; about 0.6 M to about 0.7 M;about 0.6 M to about 0.8 M; or about 0.6 M to about 1.0 M of aqueousanhydrous sodium thiosulfate.

In another embodiment, the formulation comprises about 20 mg/mL; about40 mg/mL; about 60 mg/mL; about 80 mg/mL; about 100 mg/mL; about 120mg/mL; about 140 mg/mL; about 160 mg/mL; about 180 mg/mL; about 200mg/mL; about 220 mg/mL; about 240 mg/mL; about 260 mg/mL; about 280mg/mL; about 300 mg/mL; or about 320 mg/mL of aqueous anhydrous sodiumthiosulfate.

In another embodiment, the formulation comprises about 10 mg/mL to about320 mg/mL; about 10 mg/mL to about 80 mg/mL; about 10 mg/mL to about 100mg/mL; about 10 mg/mL to about 110 mg/mL; about 10 mg/mL to about 120mg/mL; about 10 mg/mL to about 160 mg/mL; about 20 mg/mL to about 80mg/mL; about 20 mg/mL to about 100 mg/mL; about 20 mg/mL to about 110mg/mL; about 20 mg/mL to about 120 mg/mL; about 20 mg/mL to about 160mg/mL; about 30 mg/mL to about 80 mg/mL; about 30 mg/mL to about 100mg/mL; about 30 mg/mL to about 110 mg/mL; about 30 mg/mL to about 120mg/mL; about 30 mg/mL to about 160 mg/mL; about 40 mg/mL to about 80mg/mL; about 40 mg/mL to about 100 mg/mL; about 40 mg/mL to about 110mg/mL; about 40 mg/mL to about 120 mg/mL; about 40 mg/mL to about 160mg/mL; about 60 mg/mL to about 80 mg/mL; about 60 mg/mL to about 100mg/mL; about 60 mg/mL to about 110 mg/mL; about 60 mg/mL to about 120mg/mL; about 60 mg/mL to about 160 mg/mL; about 80 mg/mL to about 100mg/mL; about 80 mg/mL to about 110 mg/mL; about 80 mg/mL to about 120mg/mL; about 80 mg/mL to about 160 mg/mL; about 100 mg/mL to about 110mg/mL; about 100 mg/mL to about 120 mg/mL; or about 100 mg/mL to about160 mg/mL of aqueous anhydrous sodium thiosulfate.

In another embodiment, the formulation comprises about 1%; about 2%;about 4%; about 6%; about 8%; about 10%; about 12%; about 14%; about16%; about 18%; about 20%; about 22%; about 24%; about 26%; about 28%;about 30%; or about 32% by mass of aqueous anhydrous sodium thiosulfate.

In another embodiment, the formulation comprises about 1% to about 32%;about 1% to about 8%; about 1% to about 10%; about 1% to about 11%;about 1% to about 12%; about 1% to about 16%; about 2% to about 8%;about 2% to about 10%; about 2% to about 11%; about 2% to about 12%;about 2% to about 16%; about 3% to about 8%; about 3% to about 10%;about 3% to about 11%; about 3% to about 12%; about 3% to about 16%;about 4% to about 8%; about 4% to about 10%; about 4% to about 11%;about 4% to about 12%; about 4% to about 16%; about 6% to about 8%;about 6% to about 10%; about 6% to about 11%; about 6% to about 12%;about 6% to about 16%; about 8% to about 10%; about 8% to about 11%;about 8% to about 12%; about 8% to about 16%; about 10% to about 11%;about 10% to about 12%; or about 10% to about 16% by mass of aqueousanhydrous sodium thiosulfate.

In one embodiment described herein, the formulation comprises one ormore buffers. Typical buffers are pharmaceutically acceptable buffers.In one aspect the one or more buffer comprises acetic acid,acetylsalicylic acid, adipic acid, alginic acid, ascorbic acid, asparticacid, benzoic acid, benzenesulfonic acid, bisulfic acid, boric acid,butanoic acid, butyric acid, camphoric acid, camphorsulfonic acid,carbonic acid, citric acid, cyclopentanepropionic acid, digluconic acid,dodecylsulfic acid, ethanesulfonic acid, formic acid, fumaric acid,glyceric acid, glycerophosphoric acid, glycine, gly-glycine, glucoheptanoic acid, gluconic acid, glutamic acid, glutaric acid, glycolicacid, hemisulfic acid, heptanoic acid, hexanoic acid, hippuric acid,hydrobromic acid, hydrochloric acid, hydroiodic acid,hydroxyethanesulfonic acid, lactic acid, maleic acid, malic acid,malonic acid, mandelic acid, methanesulfonic acid, mucic acid,naphthalenesulfonic acid, naphthilic acid, nicotinic acid, nitrous acid,oxalic acid, pelargonic, phosphoric acid, propionic acid, pyruvic acid,saccharin, salicylic acid, sorbic acid, succinic acid, sulfuric acid,tartaric acid, thiocyanic acid, thioglycolic acid, thiosulfuric acid,tosylic acid, undecylenic acid, MES, bis-tris methane, ADA, ACES,bis-tris propane, PIPES, MOPSO, cholamine chloride, MOPS, BES, TES,HEPES, DIPSO, MOBS, acetamido glycine, TAPSO, TEA, POPSO, HEPPSO, EPS,HEPPS, Tricine, Tris(hydroxymethyl)aminomethane (tromethamine),glycinamide, glycylglycine, HEPBS, Bicine, TAPS, AMPB, CHES, AMP, AMPSO,CAPSO, CAPS, CABS, combinations thereof, or salts thereof. In oneaspect, the buffer comprises one or more of phosphate, sulfate,carbonate, formate, acetate, propionate, butanoate, lactate, glycine,maleate, pyruvate, citrate, aconitate, isocitrate, α-ketoglutarate,succinate, fumarate, malate, oxaloacetate, aspartate, glutamate,tris(hydroxymethyl)aminomethane (tromethamine), combinations thereof, orsalts thereof. In one aspect, the buffer is phosphate, glycine,tris(hydroxymethyl)aminomethane (tromethamine), or borate. In oneaspect, the buffer is borate. In one aspect, the buffer is phosphate. Inone aspect, the buffer is glycine. In one aspect, the buffer istris(hydroxymethyl)aminomethane (tromethamine).

In another embodiment, the one or more buffers have a concentration ofabout 0.001 M to about 0.5 M. In one aspect, the one or more buffershave a concentration of about 0.005 M to about 0.2 M; about 0.01 M toabout 0.1 M; about 0.005 M to about 0.05 M; about 0.01 M to about 0.05M; or about 0.005 M to about 0.01 M. In one aspect, the one or morebuffers have a concentration of about 0.005 M; about 0.075 M; about 0.01M; about 0.02 M; about 0.05 M, about 0.1 M; about 0.2 M, or about 0.5 M.In one aspect, the one or more buffers have a concentration of about0.01 M. In another aspect, the one or more buffers have a concentrationof about 0.05 M.

In another embodiment, the formulation comprises one or more buffersthat are titrated with one or more pharmaceutically acceptable acids orbases to adjust the pH. In one aspect, the pH of the formulation isabout 2 to about 10; about 3 to about 9; about 4 to about 8; about 4 toabout 7; about 4 to about 6; about 5 to about 6; about 5 to about 7;about 5 to about 8; about 6.0 to about 6.5; about 6 to about 7; about6.5 to about 7; or about 6 to about 8. In one aspect the pH of theformulation is about 5.0; about 5.5; about 6.0; about 6.1, about 6.2,about 6.3, about 6.4, about 6.5, about 6.6, about 6.7, about 6.8, about6.9; about 7.0; or about 7.5. In one aspect, the pH of the formulationis about 6.5.

In another embodiment, the formulation comprises one or more buffersthat are titrated with one or more pharmaceutically acceptable acids orbases to adjust the pH to about 6.5. Typically, the acid and base areselected to match the buffer and existing ions in the solution. In oneaspect, the pH is raised by the addition of a group IA hydroxide. In oneaspect, the hydroxide can be sodium hydroxide or potassium hydroxide. Inanother aspect, the pH is lowered by the addition of an acid (i.e., aproton donor). Any pharmaceutically acceptable acid can be used. In oneaspect, the acid is phosphoric acid. In another aspect, the acid ishydrochloric acid. In one aspect, both sodium hydroxide and hydrochloricacid (or phosphoric acid) are added to the formulation to titrate the pHto about 6.5.

One embodiment described herein is a pharmaceutical formulation as shownin Table 3.

TABLE 3 Exemplary Sodium Thiosulfate Formulations Component Mass/VolumeMolarity Sodium thiosulfate, anhydrous 80.0 mg/mL 0.5M Sodium phosphate,monobasic, monohydrate 1.23 mg/mL 0.0087M Sodium phosphate, dibasic,anhydrous 0.16 mg/mL 0.0012M Total phosphate buffer 1.39 mg/mL 0.01MHydrochloric acid or phosphoric acid q.s. q.s. Sodium hydroxide q.s.q.s. Final pH: 6.0-8.0 Sodium thiosulfate, anhydrous 80.0 mg/mL 0.5MBoric acid 0.25 mg/mL 0.004M Hydrochloric acid q.s. q.s. Sodiumhydroxide q.s. q.s. Final pH: 8.6-8.8 Sodium thiosulfate, anhydrous 80.0mg/mL 0.5M Glycine 0.75 mg/mL 0.01M Hydrochloric acid q.s. q.s. NaOHq.s. q.s. Final pH: 8.5-8.9 Sodium thiosulfate, anhydrous 80.0 mg/mL0.5M Tris(hydroxymethyl)aminomethane 1.21 mg/mL 0.01M (Tromethane)Hydrochloric acid q.s. q.s. NaOH q.s. q.s. Final pH: 8.5-8.9

Another embodiment described herein is a pharmaceutical formulationcomprising about 0.25 M to about 1.0 M aqueous anhydrous sodiumthiosulfate; about 1.0 mM to about 500 mM buffer, pH 5 to 9, and water.In one aspect, the pharmaceutical formulation comprises about 40 mg/mLto about 160 mg/mL aqueous anhydrous sodium thiosulfate; about 1.4 mg/mLphosphate buffer, pH 5 to 8, and water. In another aspect, thepharmaceutical formulation comprises about 4% to about 16% aqueousanhydrous sodium thiosulfate; about 0.14% sodium phosphate buffer pH 5to 8, and water. In another aspect, the pharmaceutical formulationcomprises about 40 mg/mL to about 160 mg/mL aqueous anhydrous sodiumthiosulfate; about 0.25 mg/mL borate buffer, pH 6 to 9, and water. Inanother aspect, the pharmaceutical formulation comprises about 4% toabout 16% aqueous anhydrous sodium thiosulfate; about 0.023% boratebuffer pH 6 to 9, and water. In another aspect, the pharmaceuticalformulation comprises about 40 mg/mL to about 160 mg/mL aqueousanhydrous sodium thiosulfate; about 0.75 mg/mL glycine buffer, pH 6 to9, and water. In another aspect, the pharmaceutical formulationcomprises about 4% to about 16% aqueous anhydrous sodium thiosulfate;about 0.069% glycine buffer pH 6 to 9, and water. In another aspect, thepharmaceutical formulation comprises about 40 mg/mL to about 160 mg/mLaqueous anhydrous sodium thiosulfate; about 1.21 mg/mLtris(hydroxymethyl)aminomethane (tromethamine) buffer, pH 6 to 9, andwater. In another aspect, the pharmaceutical formulation comprises about4% to about 16% aqueous anhydrous sodium thiosulfate; about 0.11%tris(hydroxymethyl)aminomethane (tromethamine) buffer pH 6 to 9, andwater.

Another embodiment described herein is a pharmaceutical formulationcomprising about 0.5 M aqueous anhydrous sodium thiosulfate, about 0.01M sodium phosphate, pH 6.5, and water. In one aspect, the pharmaceuticalformulation comprises about 80 mg/mL aqueous anhydrous sodiumthiosulfate, about 1.4 mg/mL sodium phosphate, pH 6.5, and water. Inanother aspect, the pharmaceutical formulation comprises about 8%aqueous anhydrous sodium thiosulfate; about 0.14% sodium phosphate, pH6.5.

Another embodiment described herein is a pharmaceutical formulationcomprising about 0.5 M aqueous anhydrous sodium thiosulfate, about 0.004M boric acid, pH 8.6-8.8, and water. In one aspect, the pharmaceuticalformulation comprises about 80 mg/mL aqueous anhydrous sodiumthiosulfate, about 0.25 mg/mL boric acid, pH 8.6-8.8, and water. Inanother aspect, the pharmaceutical formulation comprises about 8%aqueous anhydrous sodium thiosulfate; about 0.023% boric acid, pH8.6-8.8.

Another embodiment described herein is a pharmaceutical formulationcomprising about 0.5 M aqueous anhydrous sodium thiosulfate, about 0.01M to about 0.05 M glycine, pH 8.5-8.9, and water. In one aspect, thepharmaceutical formulation comprises about 80 mg/mL aqueous anhydroussodium thiosulfate, about 0.75 mg/mL to about 3.8 mg/mL glycine, pH8.5-8.9, and water. In another aspect, the pharmaceutical formulationcomprises about 8% aqueous anhydrous sodium thiosulfate; about 0.069% toabout 0.35% glycine, pH 8.5-8.9.

Another embodiment described herein is a pharmaceutical formulationcomprising about 0.5 M aqueous anhydrous sodium thiosulfate, about 0.01M to about 0.05 M Tris(hydroxymethyl)aminomethane (tromethamine), pH8.5-8.9, and water. In one aspect, the pharmaceutical formulationcomprises about 80 mg/mL aqueous anhydrous sodium thiosulfate, about 1.2mg/mL to about 3.6 mg/mL Tris(hydroxymethyl)aminomethane (tromethamine),pH 8.5-8.9, and water. In another aspect, the pharmaceutical formulationcomprises about 8% aqueous anhydrous sodium thiosulfate; about 0.1% toabout 0.33% Tris(hydroxymethyl)aminomethane (tromethamine), pH 8.5-8.9.

Another embodiment described herein is a pharmaceutical compositioncomprising n aqueous sodium thiosulfate and one or more pharmaceuticallyacceptable excipients.

Another embodiment described herein is a pharmaceutical compositioncomprising an aqueous sodium thiosulfate and one or morepharmaceutically acceptable buffers. In one aspect, the pH of thepharmaceutical composition is between 4 and 8. In another aspect, the pHof the pharmaceutical composition is between 5 and 7. In another aspect,the pH of the pharmaceutical composition is between 6 and 7. In anotheraspect, the pH of the pharmaceutical composition is between 6 and 8. Inanother aspect, the pH of the pharmaceutical composition is about 6. Inanother aspect, the pH of the pharmaceutical composition is about 6.5.In another aspect, the pH of the pharmaceutical composition is about 7.In another aspect, the pH of the pharmaceutical composition is about7.5.

Another embodiment described herein is a pharmaceutical compositioncomprising aqueous sodium thiosulfate, one or more pharmaceuticallyacceptable buffers, and one or more salts. In one aspect the one or moresalts comprises sodium chloride, potassium chloride, magnesium chloride,calcium chloride, sodium sulfate, potassium sulfate, magnesium sulfate,calcium sulfate, ammonium chloride, ammonium carbonate, ammoniumphosphate, ammonium sulfate, potassium citrate, potassium phosphate,potassium lactate, sodium acetate, sodium citrate, sodium lactate,sodium phosphate, among others. In one aspect, the concentration of theone or more salts is from about 0.001 M to about 0.5 M. In anotheraspect, the concentration of the one or more salts is about 0.001 M,about 0.005 M, about 0.01 M, about 0.05 M, about 0.1 M, about 0.2 M, orabout 0.5 M. In one aspect, the concentration of the one or more saltsis about 0.05 M to about 0.2 M.

Another embodiment described herein is a pharmaceutical compositioncomprising an aqueous solution of about 0.2 M to about 2 M of sodiumthiosulfate, about 0.001 M to about 0.05 M of a pharmaceuticallyacceptable buffer, and about 0.005 M to about 0.05 M of apharmaceutically acceptable salt. In one aspect, the pharmaceuticalcomposition has a pH of about 6 to 8. In one aspect, the pharmaceuticalcomposition comprises about 1 M of sodium thiosulfate, about 0.05 M of apharmaceutically acceptable buffer, and about 0.05 M of apharmaceutically acceptable salt, and a pH of about 6 to 8.

Another embodiment described herein is a sodium thiosulfatepharmaceutical composition comprising essentially no borate ions. In oneaspect, sodium thiosulfate composition comprises less than 1%, less than0.5%, less than 0.2%, less than 0.1%, less than 0.05%, or less than0.001% borate ions. In one aspect, the sodium thiosulfate compositioncomprises phosphate ions instead of borate ions.

Another embodiment is a method of manufacturing a pharmaceutical sodiumthiosulfate formulation. In one embodiment, such composition is made by:(i) combining sodium thiosulfate with a solvent and optionally, one ormore pharmaceutically acceptable excipients; (ii) transferring single ormultiple doses of the liquid or suspension into suitable containers; and(iii) sealing the containers. In one aspect, the liquid or suspension isfiltered and/or sterilized prior to or after transference to suitablecontainers. In one aspect, the container is an injectable vial or asyringe.

One embodiment is a method for preparing a formulation comprisinganhydrous sodium thiosulfate comprising combining anhydrous sodiumsulfate with one or more buffers and a solvent. The method furthercomprises adjusting the pH with pharmaceutically acceptable acids orbases. In one aspect, the buffer is sodium phosphate and the acid andbase are hydrochloric acid and sodium hydroxide. The method furthercomprises filtering the solution and transferring the solution tosuitable receptacles, sealing the receptacles, and sterilizing theformulation. In one aspect, the formulation is sterilized by filtrationand autoclaving.

Another embodiment is a formulation comprising anhydrous sodiumthiosulfate made by the method described herein. Another embodiment is ameans for preparing a formulation comprising anhydrous sodiumthiosulfate.

Another embodiment described herein is a pharmaceutical composition ofthe STS formulations described herein. The pharmaceutical compositionscan comprise one or more excipients, such as:

-   -   (i) Buffering agents: physiologically tolerated buffers to        maintain pH in a desired range, such as sodium phosphate,        bicarbonate, succinate, histidine, citrate and acetate,        sulphate, nitrate, chloride, pyruvate. Antacids such as Mg(OH)₂        or ZnCO₃ may be also used. Buffering capacity may be adjusted to        match the conditions most sensitive to pH stability.    -   (ii) Isotonicity modifiers: to minimize pain that can result        from cell damage due to osmotic pressure differences at the        injection depot. Glycerin and sodium chloride are examples.        Effective concentrations can be determined by osmometry using an        assumed osmolality of 285-315 mOsmol/kg for serum.    -   (iii) Preservatives and/or antimicrobials: multidose parenteral        preparations may require the addition of preservatives at a        sufficient concentration to minimize the risk of subjects        becoming infected upon injection and corresponding regulatory        requirements have been established. Typical preservatives        include m-cresol, phenol, methylparaben, ethylparaben,        propylparaben, butylparaben, chlorobutanol, benzyl alcohol,        phenylmercuric nitrate, thimerosol, sorbic acid, potassium        sorbate, benzoic acid, chlorocresol, and benzalkonium chloride.    -   (iv) Stabilizers: Stabilization is achieved by strengthening of        the protein-stabilising forces, by destabilization of the        denatured state, or by direct binding of excipients to the        protein. Stabilizers may be amino acids such as alanine,        arginine, aspartic acid, glycine, histidine, lysine, proline,        sugars such as glucose, sucrose, trehalose, polyols such as        glycerol, mannitol, sorbitol, salts such as potassium phosphate,        sodium sulphate, chelating agents such as EDTA, hexaphosphate,        ligands such as divalent metal ions (zinc, calcium, etc.), other        salts or organic molecules such as phenolic derivatives. In        addition, oligomers or polymers such as cyclodextrins, dextran,        dendrimers, polyethylene glycol, polyvinylpyrrolidone,        protamine, or human serum albumin may be used.    -   (v) Anti-adsorption agents: Mainly ionic or ion-ionic        surfactants or other proteins or soluble polymers are used to        coat or adsorb competitively to the inner surface of the        composition's container, e.g., poloxamer (Pluronic F-68), PEG        dodecyl ether (Brij 35), polysorbate 20 and 80, dextran,        polyethylene glycol, PEG-polyhistidine, BSA and HSA and        gelatines. Chosen concentration and type of excipient depends on        the effect to be avoided but typically, a monolayer of        surfactant is formed at the interface just above the CMC value.    -   (vi) Lyophilization or cryoprotectants: During freeze- or spray        drying, excipients may counteract the destabilising effects        caused by hydrogen bond breaking and water removal. For this        purpose, sugars and polyols may be used, but corresponding        positive effects have also been observed for surfactants, amino        acids, non-aqueous solvents, and other peptides. Trehalose is        particularly efficient at reducing moisture-induced aggregation        and also improves thermal stability potentially caused by        exposure of protein hydrophobic groups to water. Mannitol and        sucrose may also be used, either as sole lyo/cryoprotectant or        in combination with each other where higher ratios of mannitol        or sucrose are known to enhance physical stability of a        lyophilized cake. Mannitol may also be combined with trehalose.        Trehalose may also be combined with sorbitol or sorbitol may be        used as the sole protectant. Starch or starch derivatives may        also be used.    -   (vii) Oxidation protection agents: antioxidants such as ascorbic        acid, ectoine, methionine, glutathione, monothioglycerol, morin,        polyethylenimine (PEI), propyl gallate, vitamin E, chelating        agents such aus citric acid, EDTA, hexaphosphate, thioglycolic        acid.    -   (viii) Viscosifiers or viscosity enhancers: retard settling of        the particles in the vial and syringe and are used in order to        facilitate mixing and resuspension of the particles and to make        the suspension easier to inject (i.e., low force on the syringe        plunger). Suitable viscosifiers or viscosity enhancers are, for        example, carbomer viscosifiers like Carbopol 940, Carbopol        Ultrez 10, cellulose derivatives like        hydroxypropylmethylcellulose (hypromellose, HPMC) or        diethylaminoethyl cellulose (DEAE or DEAE-C), colloidal        magnesium silicate (Veegum) or sodium silicate, hydroxyapatite        gel, tricalcium phosphate gel, xanthans, carrageenans like        Satiagum UTC 30, aliphatic poly(hydroxy acids), such as        poly(D,L- or L-lactic acid) (PLA) and poly(glycolic acid) (PGA)        and their copolymers (PLGA), terpolymers of D,L-lactide,        glycolide and caprolactone, poloxamers, hydrophilic        poly(oxyethylene) blocks and hydrophobic poly(oxypropylene)        blocks to make up a triblock of        poly(oxyethylene)-poly(oxypropylene)-poly(oxyethylene) (e.g.,        Pluronic™) polyetherester copolymer, such as a polyethylene        glycol terephthalate/polybutylene terephthalate copolymer,        sucrose acetate isobutyrate (SAIB), dextran or derivatives        thereof, combinations of dextrans and PEG, polydimethylsiloxane,        collagen, chitosan, polyvinyl alcohol (PVA) and derivatives,        polyalkylimides, poly (acrylamide-co-diallyldimethyl ammonium        (DADMA)), polyvinylpyrrolidone (PVP), glycosaminoglycans (GAGs)        such as dermatan sulfate, chondroitin sulfate, keratan sulfate,        heparin, heparan sulfate, hyaluronan, ABA triblock or AB block        copolymers composed of hydrophobic A-blocks, such as polylactide        (PLA) or poly(lactide-co-glycolide) (PLGA), and hydrophilic        B-blocks, such as polyethylene glycol (PEG) or polyvinyl        pyrrolidone. Such block copolymers as well as the abovementioned        poloxamers may exhibit reverse thermal gelation behavior (fluid        state at room temperature to facilitate administration and gel        state above sol-gel transition temperature at body temperature        after injection).    -   (ix) Diffusion agents: modifies the permeability of connective        tissue through the hydrolysis of components of the extracellular        matrix in the interstitial space such as, but not limited to,        hyaluronic acid, a polysaccharide found in the intercellular        space of connective tissue. A spreading agent such as, but not        limited to, hyaluronidase temporarily decreases the viscosity of        the extracellular matrix and promotes diffusion of injected        drugs.    -   (x) Other auxiliary agents: such as wetting agents, viscosity        modifiers, antibiotics, hyaluronidase. Acids and bases such as        hydrochloric acid and sodium hydroxide are auxiliary agents        necessary for pH adjustment during manufacture.        The foregoing list is not meant to be exclusive, but instead        merely representative of the classes of excipients and the        particular excipients that may be used in pharmaceutical as        described herein.

The STS formulation may be provided as a liquid, a suspension, or as adry composition.

In one embodiment, the STS formulation is a sterile liquid composition.The formulation may be administered intravenously by either directvenipuncture or using an intravenous line.

In one embodiment, the pharmaceutical composition is a sterile solution.

In another embodiment, the STS formulation is a dry composition.Suitable methods of drying are, for example, spray drying, andlyophilization (freeze-drying). In one aspect, the STS formulation isprepared as a solution and then dried by lyophilization. In anotheraspect, the STS formulation is prepared as a dry composition thatreconstituted immediately prior to use with sterile water for injectionand then administered intravenously by either direct venipuncture orusing an intravenous line.

In another embodiment, the composition is a dry or lyophilizedcomposition that can be reconstituted with sterile water for injection,PBS, saline, or other sterile, parenterally compatible solution toproduce a solution suitable for injection. In one aspect, thecomposition comprises about 20 mg to 32 g of anhydrous sodiumthiosulfate. In one aspect, the composition comprises about 98% by massof anhydrous sodium thiosulfate. In one aspect, the compositioncomprises about 1% to 2% by mass of one or more buffers. Upon additionof a specified amount of sterile water for injection, the reconstituteddry or lyophilized composition comprises about 0.5 M aqueous anhydroussodium thiosulfate, about 0.01 M sodium phosphate, pH 6.5, and water.

Pharmaceutical compositions suitable for administration by injectioninclude sterile aqueous solutions, suspensions, or dispersions andsterile powders or lyophilizates for the extemporaneous preparation ofsterile injectable solutions or dispersion.

For intravenous administration, suitable solvents include sterile waterfor injection, phosphate buffered saline (PBS), physiological saline, orRinger's solution. In all cases, the composition should be sterile andshould be fluid to the extent that easy syringability exists. Preferredpharmaceutical formulations are stable under the conditions ofmanufacture and storage and must be preserved against the contaminatingaction of microorganisms such as bacteria and fungi. In general, therelevant solvent or carrier can be a solvent or dispersion mediumcontaining, for example, water, buffers, ethanol, polyol (for example,glycerol, propylene glycol, and liquid polyethylene glycol, and thelike), and suitable mixtures thereof. Prevention of the action ofmicroorganisms can be achieved by various antibacterial and antifungalagents, for example, parabens, chlorobutanol, phenol, ascorbic acid,thimerosal, and the like. In many cases, it will be preferable toinclude isotonic agents, for example, sugars, polyalcohols such asmannitol, amino acids, sorbitol, sodium chloride, or combinationsthereof in the composition.

Certain injectable compositions are aqueous isotonic solutions orsuspensions, and suppositories are advantageously prepared from fattyemulsions or suspensions. Said compositions may be sterilized and/orcontain adjuvants, such as preserving, stabilizing, wetting, oremulsifying agents, solution promoters, salts for regulating the osmoticpressure, and/or buffers. In addition, they may also contain othertherapeutically valuable substances. Said compositions are preparedaccording to conventional mixing, granulating, or coating methods,respectively, and may contain about 0.1-75%, or contain about 1-50%, ofthe active ingredient. In one embodiment described herein, thecomposition comprises about 7.5% of the active ingredient, aqueousanhydrous sodium thiosulfate. As a dry composition suitable forreconstitution, the composition may comprise up to 98% sodiumthiosulfate.

Sterile injectable solutions or suspensions can be prepared byincorporating sodium thiosulfate in the required amount in anappropriate solvent with one or a combination of ingredients, asrequired, followed by filtration and/or sterilization. Generally,solutions or suspensions are prepared by incorporating the activecompound into a sterile vehicle such as sterile water or PBS and anyexcipients. In one aspect, sterilization is accomplished by autoclavingthe final formulation in a vial for injection. In the case of sterilepowders for the preparation of sterile injectable solutions, thepreferred preparation methods are vacuum drying and freeze-drying whichyield a powder of the active ingredient plus any additional excipientsfrom a previously sterile-filtered solution thereof.

Transmucosal or transdermal administration means are also possible.Suitable compositions for transdermal application include an effectiveamount of a biologically active agent with a suitable carrier. Carrierssuitable for transdermal delivery include absorbable pharmacologicallyacceptable solvents to assist passage through the skin of the host. Forexample, transdermal devices are in the form of a bandage comprising abacking member, a reservoir containing the compound optionally withcarriers, optionally a rate controlling barrier to deliver the compoundof the skin of the host at a controlled and predetermined rate over aprolonged period of time, and means to secure the device to the skin.

Suitable compositions for topical application, e.g., to the skin, eyes,or joints, include aqueous solutions, suspensions, ointments, creams,gels or sprayable formulations, e.g., for delivery by aerosol or thelike. Such topical delivery systems will in particular be appropriatefor dermal application. They are thus particularly suited for use intopical, including cosmetic, formulations well known in the art. Suchmay contain solubilizers, stabilizers, tonicity enhancing agents,buffers, or preservatives.

As used herein, a topical application may also pertain to an inhalationor to an intranasal application. They may be conveniently delivered inthe form of a dry powder (either alone, as a mixture, for example a dryblend with lactose, or a mixed component particle, for example withphospholipids) from a dry powder inhaler or an aerosol spraypresentation from a pressurised container, pump, spray, atomizer ornebuliser, with or without the use of a suitable propellant.

Also described herein are pharmaceutical compositions and dosage formscomprising one or more agents that reduce the rate by which thecompositions described herein as active ingredients will decompose. Suchagents, which are referred to herein as “stabilizers,” include, but arenot limited to, antioxidants such as ascorbic acid, pH buffers, salts,sugars, etc.

Another embodiment described herein, is a pharmaceutical compositioncomprising anhydrous sodium thiosulfate. In one aspect, the compositioncomprises any of the formulations shown in the Tables or Examplesdescribed herein. Any of the components in the formulations describedherein, shown in the Tables, or illustrated in the Examples can beincreased, decreased, combined, substituted, or omitted to provide for aformulation comprising about 100% by weight. Such compositions arehereby disclosed as if they were expressly disclosed herein.

The effective amount of an active pharmaceutical ingredient to beadministered therapeutically will depend, for example, upon thetherapeutic context and objectives. One having ordinary skill in the artwill appreciate that the appropriate dosage levels for treatment willvary depending, in part, upon the concentration of the STS formulation,the dosing regimen for which the STS formulation is being used, theroute of administration, and the subject's size (body weight or bodysurface area) and condition (the age and general health) of the patient.Accordingly, the clinician can titer the dosage and modify the route ofadministration to obtain the optimal therapeutic effect.

The frequency of dosing will depend upon the pharmacokinetic parametersof the therapeutic agent incorporated into the STS formulation beingused. The composition can be administered as a single dose, as two ormore doses (which may or may not contain the same amount of the desiredmolecule) over time, or as a continuous infusion via an implantationdevice or catheter. Further refinement of the appropriate dosage isroutinely made by those of ordinary skill in the art and is within theambit of tasks routinely performed by them. Appropriate dosages can beascertained through use of appropriate dose-response data.

The sodium thiosulfate can be administered, for example, 1×, 2×, 3×, 4×,5×, 6×, or even more times per day. One or more doses can beadministered, for example, for 1, 2, 3, 4, 5, 6, 7 days, or even longer.One or more doses can be administered, for example, for 1, 2, 3, 4weeks, or even longer. One or more doses can be administered, forexample, for 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 months, 1 year, 2,years, 3 years, 4 years, 5 years, over 5 years, a decade, multipledecades, or even longer. One or more doses can be administered at aregular interval until the subject or subject in need thereof, does notrequire treatment, prophylaxis, or amelioration of ototoxicity.

In one embodiment, the pharmaceutical composition described herein isadministered in one or multiple doses simultaneously. For example, twoor more identical doses are administered at one time. In anotherembodiment, two or more different doses are administered at one time.Such dual or different simultaneous doses can be used to provide aneffective amount of the pharmaceutical composition to a subject in needthereof.

In another embodiment, the pharmaceutical compositions described hereinmay be used to treat, prevent, retard the progression of, delay theonset, ameliorate, reduce the symptoms of, or prophylaxis ofototoxicity.

In one embodiment, the STS formulation is sufficiently dosed in thecomposition to provide therapeutically effective amounts of sodiumthiosulfate in one application. In one aspect, one application of STSformulation is sufficient for about 1 day, about 2 days, about 3 days,about 4 days, about 5 days, about 1 week, about 2 weeks, about 3 weeks,about 4 weeks, one month, 2 months, 3 months, 4 months, 6 months, 9months, one year, 2 years, 3 years, 4 years, or even longer.

The phrases and terms “can be administered by injection,” “injectable,”or “injectability” refer to a combination of factors such as a certainforce applied to a plunger of a syringe containing the STS formulationsdescribed herein dissolved in a liquid at a certain concentration (w/v)and at a certain temperature, a needle of a given inner diameterconnected to the outlet of such syringe, and the time required toextrude a certain volume of the STS formulations from the syringethrough the needle.

In one embodiment, the STS formulation is provided as a single dose,meaning that the container in which it is supplied contains onepharmaceutical dose.

In another embodiment, the composition is provided as a multiple dosecomposition, meaning that it contains more than one therapeutic dose.Preferably, a multiple dose composition contains at least 2 doses. Suchmultiple dose STS formulations either can be used for different subjectsin need thereof or is intended for use in one subject, wherein theremaining doses are stored after the application of the first dose untilneeded.

In another embodiment, the STS formulation is comprised in one or morecontainers. For liquid or suspension compositions, the container ispreferably a single chamber syringe. For dry compositions, preferablythe container is a dual-chamber syringe. The dry composition is providedin a first chamber of the dual-chamber syringe and reconstitutionsolution is provided in a second chamber of the dual-chamber syringe.

Prior to administering the dry STS formulation to a subject in needthereof, the dry composition is reconstituted. Reconstitution can takeplace in the container in which the dry STS formulation is provided,such as in a vial, syringe, dual-chamber syringe, ampoule, or cartridge.Reconstitution is performed by adding a predefined amount ofreconstitution solution to the dry composition. Reconstitution solutionsare sterile liquids, such as water for injection, phosphate bufferedsaline, isotonic saline, or other buffers, which may contain furtherexcipients, such as preservatives and/or antimicrobials, such as, forexample, benzylalcohol and cresol. Preferably, the reconstitutionsolution is sterile water for injection. Alternatively, thereconstitution solution is sterile phosphate buffered saline (PBS) orphysiological saline.

Another embodiment is a method of preparing a reconstituted compositioncomprising a therapeutically effective amount of a STS formulation, andoptionally one or more pharmaceutically acceptable excipients, themethod comprising the step of contacting the composition with a volumeof reconstitution vehicle. The reconstituted STS formulation may then beadministered by injection or other routes.

Another embodiment is a reconstituted composition comprising atherapeutically effective amount of a STS formulation, a reconstitutionvehicle, and optionally one or more pharmaceutically acceptableexcipients.

Another embodiment is a pre-filled syringe comprising a solution or asuspension comprising a therapeutically effective amount of a STSformulation, and optionally one or more pharmaceutically acceptableexcipients. In one aspect, the syringe is filled with between about 0.01mL and about 5 mL of a STS formulation as described herein. In oneaspect, the syringe is filled with between about 0.05 mL and about 5 mL,between about 1 mL and about 2 mL, between about 0.1 mL and about 0.15mL, between about 0.1 mL, about 0.5 mL, between about 0.15 mL and about0.175 mL, or about 0.5 to about 5 mL. In one embodiment, the syringe isfilled with 0.165 mL of a STS formulation as described herein. In someaspects, a syringe is filled with about 0.01 mL, about 0.02 mL, about0.03 mL, about 0.04 mL, about 0.05 mL, about 0.06 mL, about 0.07 mL,about 0.08 mL, about 0.09 mL, about 0.1 mL, about 0.2 mL, about 0.3 mL,about 0.4 mL, about 0.5 mL, about 0.6 mL, about 0.7 mL, about 0.8 mL,about 0.9 mL, about 1 mL, about 1.2 mL, about 1.5 mL, about 1.75 mL,about 2 mL, about 2.5 mL, about 3 mL, about 4 mL, or about 5 mL of a STSformulation as described herein. A syringe is often filled with morethan the desired dose to be administered to the patient, to take intoaccount wastage due to “dead space” within the syringe and needle. Theremay also be a pre-determined amount of waste when the syringe is primedby the physician, so that it is ready to inject the patient.

In one embodiment, a syringe is filled with a dosage volume (e.g., thevolume of medicament intended for delivery to the patent) of betweenabout 0.01 mL and about 5 mL depending on the route of injection (e.g.,between about 0.01 mL and about 0.1 mL, between about 0.1 mL and about0.5 mL, between about 0.2 mL and about 2 mL, between about 0.5 mL andabout 5 mL, or between about 1 mL and about 5 mL) of a STS formulationas described herein.

In one embodiment, when the composition is intended for injection, asyringe is filled with a dosage volume of between about 0.01 mL andabout 5.0 mL of a STS formulation solution or suspension with a drugconcentration of 0.1 mg/mL to 40 mg/mL as described herein. In someaspects, a syringe is filled with about 0.01 mL, about 0.02 mL, about0.03 mL, about 0.04 mL, about 0.05 mL, about 0.06 mL, about 0.07 mL,about 0.08 mL, about 0.09 mL, about 0.1 mL, about 0.2 mL, about 0.3 mL,about 0.4 mL, about 0.5 mL, about 0.6 mL, about 0.7 mL, about 0.8 mL,about 0.9 mL, about 1 mL, about 1.2 mL, about 1.5 mL, about 1.75 mL,about 2 mL, about 2.5 mL, about 3 mL, about 4 mL, or about 5 mL of a STSformulation as described herein for delivery to a patient in needthereof.

The outlet of a syringe comprising a medicament may be reversibly sealedto maintain sterility of the medicament. This sealing may be achieved bya sealing device as is known in the art, such as a luer lock or a tamperresistant seal.

Another embodiment is a kit comprising one or more vials or pre-filledsyringes comprising a solution or suspension of one or more STSformulations as described herein. In one embodiment, such a kitcomprises a vial or pre-filled syringe comprising STS formulations asdescribed herein in a blister pack or a sealed sleeve. The blister packor sleeve may be sterile on the inside. In one aspect, vials orpre-filled syringes as described herein may be placed inside suchblister packs or sleeves prior to undergoing sterilization, for exampleterminal sterilization. The kit may also comprise documents comprisingprescribing information or instructions for use.

Such a kit may further comprise one or more needles for administrationof STS formulations as described herein. Such kits may further compriseinstructions for use, a drug label, contraindications, warnings, orother relevant information. One embodiment described herein is a cartonor package comprising one or more vials or pre-filled syringescomprising one or more STS formulations as described herein containedwithin a blister pack, a syringe, a needle, and optionally documents orinstructions for administration, a drug label, contraindications,warnings, or other relevant information.

A terminal sterilization process may be used to sterilize the vials orsyringes and such a process may use a known process such as autoclaving,ethylene oxide, or a hydrogen peroxide (H₂O₂) sterilization process.Needles to be used with the syringe can be sterilised by the samemethod, as can kits described herein. In one aspect, a package isexposed to autoclaving or a sterilizing gas until the outside of thepackage is sterile. Following such a process, the outer surface of thesyringe may remain sterile (while in its blister pack) for up to 6months, 9 months, 12 months, 15 months, 18 months, 24 months or longer.Thus, in one embodiment, a pre-filed syringe as described herein (in itsblister pack) may have a shelf life of up to 6 months, 9 months, 12months, 15 months, 18 months, 24 months, or even longer. In oneembodiment, less than one syringe in a million has detectable microbialpresence on the outside of the syringe after 18 months of storage. Inone aspect, the pre-filled syringe has been sterilised using ethyleneoxide with a Sterility Assurance Level of at least 10⁻⁶. In anotheraspect, the pre-filled syringe has been sterilised using hydrogenperoxide with a Sterility Assurance Level of at least 10⁻⁶. Significantamounts of the sterilising gas should not enter the variable volumechamber of the syringe. The term “significant amounts” As used herein,refers to an amount of gas that would cause unacceptable modification ofthe STS formulation solution or suspension within the variable volumechamber. In one embodiment, the sterilization process causes ≤10%(preferably ≤5%, ≤2%, ≤1%, ≤0.5%, ≤0.1%) alkylation of the STSformulation. In one embodiment, the pre-filled syringe has beensterilised using ethylene oxide, but the outer surface of the syringehas ≤1 ppm, preferably ≤0.2 ppm ethylene oxide residue. In oneembodiment, the pre-filled syringe has been sterilised using hydrogenperoxide, but the outer surface of the syringe has ≤1 ppm, preferably≤0.2 ppm hydrogen peroxide residue. In another embodiment, thepre-filled syringe has been sterilised using ethylene oxide, and thetotal ethylene oxide residue found on the outside of the syringe andinside of the blister pack is ≤0.1 mg. In another embodiment, thepre-filled syringe has been sterilised using hydrogen peroxide, and thetotal hydrogen peroxide residue found on the outside of the syringe andinside of the blister pack is ≤0.1 mg.

Another embodiment described herein is a kit comprising sodiumthiosulfate for administration to a subject. For liquid and suspensioncompositions, and when the administration device is simply a hypodermicsyringe, the kit may comprise the syringe, a needle, and a containercomprising the STS formulation for use with the syringe. In case of adry composition, the container may have one chamber containing the drySTS composition, and a second chamber comprising a reconstitutionsolution. In one embodiment, the injection device is a hypodermicsyringe adapted so the container with STS formulation can engage withthe injection device such that the liquid, suspension, or reconstituteddry composition in the container is in fluid connection with the outletof the injection device. Examples of administration devices include butare not limited to hypodermic syringes and pen injector devices.

Another embodiment comprises a kit comprising a needle and a containercontaining the STS formulation composition and optionally furthercontaining a reconstitution solution, the container being adapted foruse with the needle. In one aspect, the container is a pre-filledsyringe. In another aspect, the container is dual chambered syringe. Inanother aspect, the STS formulation is provided as a lyophilisate in asealed vial and a reconstitution solution is provided in anotherreceptacle such as a sealed vial or a pre-filled syringe. An appropriatevolume of the reconstitution solution is used to resuspend thelyophilisate. In another aspect, the kit comprises instructions, labels,or other written matter.

Another embodiment is a cartridge containing a composition describedherein for use with a pen injector device. The cartridge may contain asingle dose or plurality of doses of the STS formulation.

In another embodiment, one or more STS formulations are simultaneouslyadministered, with each STS formulation having either separate orrelated biological activities.

In an alternative embodiment, the STS formulation is combined with asecond biologically active compound in such way that the STS formulationis administered to a subject in need thereof first, followed by theadministration of the second compound. Alternatively, the STSformulation composition is administered to a subject in need thereofafter another compound has been administered to the same subject.

Another embodiment described herein is a method for reducing ototoxicityin patients (e.g., pediatric patients) having a cancer and who arereceiving a platinum based chemotherapeutic for treatment of the cancer.The methods include administering an effective amount of STS to thepatient. In one aspect, the STS comprises one or more of the STSformulations described herein. It was found that STS significantlyreduces the risk of ototoxicity particularly in pediatric patientpopulations. Therefore, one embodiment, described herein is a method forreducing ototoxicity in a pediatric patient having a cancer andreceiving a platinum based chemotherapeutic comprising administering aneffective amount of STS to the pediatric patient. In some aspects, thepediatric patient already has incurred ototoxicity and theadministration of STS reduces the amount of future ototoxicity incurredby the pediatric patient.

The risk of a pediatric patient having detectable ototoxicity, forexample, hearing loss measured by the Brock scale of ≥1 is significantlyreduced by treatment with STS following the administration of acisplatinum based chemotherapeutic. The risk of ototoxicity is relevantto a pediatric patient not receiving STS. Thus, in some embodiments, thelikelihood of a pediatric patient incurring any ototoxicity is reducedby STS administration by about 10% to about 100%, about 30% to about 90%or about 40% to about 70%, including each integer within the specifiedranges. In some embodiments, the risk of a pediatric patient incurringany ototoxicity is reduced by STS administration by about 10%, about20%, about 30%, about 40%, about 50%, about 60%, about 70%, about 80%,about 90%, or even about 100%. In some aspects, the risk of a pediatricpatient incurring ototoxicity according to ASHA-defined hearing losscriteria is about 50%.

Similarly, treatment of a pediatric patient with STS can further reducelong-term ototoxicity in pediatric patients having a cancer andreceiving a platinum based chemotherapeutic. It is known that followingtreatment with STS, pediatric patients can exhibit ototoxicity weeks,months, or even years following the succession of treatment with theplatinum based chemotherapeutic. Thus, another embodiment describedherein is a method of reducing long-term ototoxicity in a pediatricpatient having a cancer and receiving a platinum based chemotherapeuticcomprising administering an effective amount of sodium thiosulfate tothe pediatric patient.

As described above, it is thought that platinum-based chemotherapeuticagents, such as cisplatin, exert ototoxic effects by concentrating inthe aural cavity of a patient (e.g., a pediatric patient). It is furthercontemplated herein that STS can reduce the amount of platinum basedchemotherapeutic agent in the aural cavity by binding to the agent andreducing its accumulation in the aural cavity. Another embodimentdescribed herein is a method of reducing a concentration of cisplatin inan aural cavity of a pediatric patient having a cancer and receiving aplatinum based chemotherapeutic comprising administering an effectiveamount of sodium thiosulfate to the pediatric patient. In some aspects,the concentration of cisplatin is reduced by in the aural cavity byabout 50%, about 60%, about 70%, about 80%, about 90%, or about 100%compared to a pediatric patient receiving a platinum basedchemotherapeutic and not receiving STS. In some aspects, theconcentration of cisplatin is not detectable in the aural cavity. Insome aspects, the patient administered STS is less susceptible toincurring ototoxicity because the amount of platinum basedchemotherapeutic in the aural cavity is reduced. Methods for detectingcisplatin in the aural cavity include extracting a sample from the auralcavity and measuring the amount of cisplatin present in the sample, forexample, through high performance liquid chromatography (HPLC) or othermethods known in the art.

The methods described herein are also useful for preventing orinhibiting ototoxicity in a pediatric patient having a cancer and who isreceiving a platinum based chemotherapeutic for treatment of the cancer.It was found that pediatric patients are particularly susceptible toincurring ototoxicity and prophylactically treating the pediatricpatient can reduce the ototoxicity in the pediatric patient. Therefore,another embodiment described herein is a method of prophylacticallytreating a pediatric patient having a cancer and receiving a platinumbased chemotherapeutic with an effective amount of STS, wherein thetreatment reduces a likelihood of the pediatric patient incurringototoxicity.

It has been determined that certain genetic variations can cause anincreased likelihood of a pediatric patient having ototoxicity and theseverity of ototoxicity in the patient. The genes TPMT, COMT, and ABCC3have been shown to put pediatric patients at a greater risk forincurring ototoxicity. See Ross et al., “Genetic variants in TPMT andCOMT are associated with hearing loss in children receiving cisplatinchemotherapy,” Nat. Genet. 41: 1345-1349 (2009); Pussegoda et al.,“Replication of TPMT and ABCC3 genetic variants is highly associatedwith cisplatin-induced hearing loss in children,” Clin. Pharmacol. Ther.94: 243-251 (2013). In addition, it has more recently been shown thatsingle nucleotide polymorphism in the ACYP2 gene at the locus rs1872328are associated with cisplatin-based ototoxicity. See Xu, K. et al.,“Common variants in ACYP2 influence susceptibility to cisplatin-inducedhearing loss,” Nat. Genet. 47(3): 263-266 (2015). Thus, in someembodiments a pediatric patient receiving a cisplatin basedchemotherapeutic is identified as being at high risk for having agenetic variation in one or more of the genes TPMT, COMT, ABCC3, andACYP2 and treated with STS to reduce the likelihood, prevent, inhibit,or treat ototoxicity.

In some embodiments described herein, the pediatric patient has a cancerand is receiving a platinum based chemotherapeutic. In some otherembodiments, the pediatric patient does not yet have a diagnosed cancerbut is being treated with a platinum based chemotherapeutic. Anyplatinum-based drug would be expected to be scavenged by STS and reduceototoxicity. Thus, in some embodiments, the platinum basedchemotherapeutic comprises cisplatin, carboplatin, oxaliplatin,nedaplatin, triplatin tetranitrate, phenanthriplatin, picoplatin, andsatraplatin. In some aspects, the platinum based chemotherapeutic iscisplatin.

The amount of platinum based chemotherapeutic that a pediatric patientis receiving is determined by the treating physician, the type ofdisease or cancer that is being treated, and the age or weight of thepediatric patient. In some aspects, the amount of platinum basedchemotherapeutic (e.g., cisplatin) per cycle of administration is about1 mg/kg to about 5 mg/kg, including each integer within the specifiedrange. In some aspects, the amount of platinum based chemotherapeutic(e.g., cisplatin) per cycle of administration is about 10 mg/m² to about300 mg/m², 10 mg/m² to about 100 mg/m², or about 40 mg/m² to about 80mg/m², including each integer within the specified ranges.

Many cancers are treated with platinum-based chemotherapeutics inpediatric patients, for which STS may be administered. In some aspectsof the embodiments described herein, a pediatric patient has a cancerthat is being treated with a platinum based chemotherapeutic followed bySTS, wherein the cancer is localized or disseminated. In some aspects,the cancer is low-risk, medium risk, or high risk (e.g., metastatic)cancer. In some aspects, the cancer is low-risk or medium-risk. In someaspects, the cancer being treated with a platinum based chemotherapeuticis localized and is not disseminated or metastatic. Non-limiting andexemplary cancers that can be treated with a platinum basedchemotherapeutic followed by STS comprise germ cell tumors (e.g.,testicular cancer or ovarian cancer), hepatoblastoma, medulloblastoma,neuroblastoma, and osteosarcoma. In some aspects, a pediatric patienthas a hepatoblastoma cancer and is being treated with a platinum basedchemotherapeutic and STS. In some aspects, a pediatric patient has alow-risk or medium-risk hepatoblastoma cancer and is being treated witha platinum based chemotherapeutic and STS.

In some embodiments, the STS is administered to a pediatric patientreceiving treatment with a platinum-based chemotherapeutic agent priorto, concurrently with, or after the administration of the platinum basedchemotherapeutic. In some aspects, the STS is administered 0 minutes orabout 5 minutes to about 96 hours after the administration of theplatinum based chemotherapeutic, including each integer of time withinthe specified range. In some aspects, the STS is administered about 30minutes to about 24 hours, about 1 hour to about 24 hours, about 1 toabout 12 hours, about 1 hour to about 8 hours, or about 4 hours to about7 hours after the administration of the platinum based chemotherapeutic,including each integer of time within the specified ranges. In oneaspect, the STS is administered about 6 hours after the administrationof the platinum based chemotherapeutic.

The administration of STS may be carried out in any way that is knownfor administering STS. For example, STS may be administered parenterallyor enterally. If administered parenterally, the STS can be administeredintravenously (IV), subcutaneously (SC), or intramuscularly (IM).Enteral administration includes oral, sublingual, or rectal. In oneembodiment, the STS is administered intravenously.

An effective amount of STS is an amount of STS, which prevents, reduces,or inhibits ototoxicity in a pediatric patient receiving a platinumbased chemotherapeutic. In some embodiments, the amount of STSadministered is about 0.5 g/m² to about 50 g/m², about 1 g/m² to about25 g/m² or 15 g/m² to about 25 g/m², including each integer within thespecified ranges. In some embodiments, the amount of STS administered isabout 1 g/m², about 2 g/m², about 4 g/m², about 6 g/m², about 8 g/m²,about 10 g/m², about 15 g/m², about 20 g/m², about 25 g/m², about 30g/m², about 40 g/m², or about 50 g/m². The effective amount of STS isadministered prior to, concomitantly with, or following each cycle ofplatinum based chemotherapy.

Some additional embodiments described herein are dosing regimens fortreating a cancer in a pediatric patient, which include administering aplatinum based chemotherapeutic and STS. One embodiment is a dosingregimen for treating hepatoblastoma in a pediatric patient that includesadministering a dose of about 1 mg/kg to about 5 mg/kg or about 10 mg/m²to about 300 mg/m² per cycle of a platinum based chemotherapeutic,including each integer within the recited range; and also administeringabout 5 g/m² to about 25 g/m² of STS per cycle of the platinum basedchemotherapeutic, including each integer within the specified ranges. Inone aspect, the STS is administered from about 2 hours to about 6 hoursafter the administration of the platinum based chemotherapeutic,including each integer within the recited range.

The measurement of ototoxicity following administration of the platinumbased chemotherapeutic and STS should be carried out after a period timefollowing the last treatment with the platinum based chemotherapeuticand STS. In some aspects, the ototoxicity is measured after a timeperiod of at least 3 days to about 3 months, 1 week to about 3 months, 1week to about 2 months, or 1 week to about 4 weeks following the lasttreatment with the platinum based chemotherapeutic and STS, includingeach integer within the specified ranges of time. In one aspect, theototoxicity is measured after a time period of at least 4 weeks from thelast treatment with the platinum based chemotherapeutic and STS.

The measurement of ototoxicity following administration of the platinumbased chemotherapeutic and STS can be carried out multiple times and upto years following the last administration of STS and the platinum basedchemotherapeutic. Audiometric methods for measuring hearing loss arewell known to those of ordinary skill in the art and are used inconjunction with various scales to assess ototoxicity. Assessingototoxicity allows, for example, the assessment of any potentialototoxicity or long-term prevention of ototoxicity by STS. Theassessment of ototoxicity can be determined by one or more criteriaknown in the art. For example, ototoxicity may include assessment by thetinnitus functional index, Brock grading, Children's Cancer Group 1996study scale, Children's Hospital Boston scale, the Chang andChinosornvatana scale, the American Speech-Language-Hearing Associationcriteria, the Common Terminology Criteria for Adverse Events scale(CTCAE pediatric grading), or the International Society of PediatricOncology Boston Ototoxicity Scale or a combination of these scales. SeeGurney, et al., “Oncology,” J. Clin. Onc. 30(19): 2303-2306 (2012). Themeasurement of hearing function should in most cases be completed priorto treatment with an ototoxic drug such as a cisplatin or anotherplatinum based chemotherapeutic. This establishes a baseline measure ofhearing function to which any potential ototoxic effects can becompared. Thus, changes in hearing or increase or decrease inototoxicity is computed relative to baseline measures prior to thepatient receiving a platinum based chemotherapeutic or sodiumthiosulfate or both.

The Brock scale is defined as follows: a <40 dB hearing loss at allfrequencies, which indicates a grade 0 or minimal hearing loss; a ≥40 dBhearing loss at 8,000 Hz only, which indicates a grade 1 or mild hearingloss; a ≥40 dB hearing loss at 4,000 Hz and above, which indicates agrade 2 or moderate hearing loss; a ≥40 dB hearing loss at 2,000 Hz andabove, which indicates a grade 3 or marked hearing loss; or a ≥40 dBhearing loss at 1,000 Hz and above, which indicates a grade 4 or severehearing loss.

The CTCAE scale is based on hearing at 1, 2, 3, 4, 6, and 8 kHz. Grade 1is a threshold shift >20 dB at 8 kHZ in at least 1 ear; Grade 2 is athreshold shift >20 dB at 4 kHz and above in at least 1 ear; Grade 3 ishearing loss sufficient to indicate therapeutic intervention includinghearing aids, a threshold shift >20 dB at 3 kHz and above in at least 1ear; speech and language svcs indicated; and grade 4 is the audiologicindication of cochlear implant and speech and language svcs indicated.

The Children's Cancer Group 1996 scale is defined as follows: ≥40 dB HLloss at 6,000 and/or 8,000 Hz is indicative of grade 1, >25 dB HL lossat 3,000 and/or 4,000 Hz is indicative of grade 2, >25 dB HL loss at2,000 Hz is indicative of grade 3; and a ≥40 dB HL loss at 2,000 Hz isindicative of grade 4. Children's Hospital Boston scale is defined asfollows: <20 dB hearing loss at frequencies 500-8,000 Hz; no functionalhearing loss; >20 dB hearing loss above 4,000 Hz; functional loss:slight hearing loss that may result in decreased musical appreciationindicative of a grade 1; >20 dB hearing loss at 4,000 Hz and above;functional loss: educationally significant hearing loss indicative ofgrade 2; >20 dB hearing loss at 2,000 Hz and above; functional loss:severe hearing loss requiring hearing aids indicative of grade 3.

The Chang and Chinosornvatana scale is defined as ≤20 dB at 1, 2, and 4kHz is indicative of normal hearing; (1a) ≥40 dB at any frequency 6 to12 kHz; (1b) >20 and <40 dB at 4 kHz is indicative of grade 1a and 1b,respectively; (2a) ≥40 dB at 4 kHz and above; (2b) >20 and <40 dB at anyfrequency below 4 kHz is indicative of grade 2a and 2b, respectively;≥40 dB at 2 or 3 kHz and above is indicative of grade 3; and ≥40 dB at 1kHz and above is indicative of grade 4.

The American Speech-Language-Hearing Association criteria is defined as(1) ≥20 dB decrease at any one frequency; (2) ≥10 dB decrease at two ormore adjacent frequencies; or (3) loss of response at three adjacentfrequencies at which responses were previously obtained. The ASHAfurther specifies that a significant change in hearing sensitivity mustbe confirmed by repeat testing to be considered valid.

International Society of Pediatric Oncology Boston Ototoxicity Scale isdefined as ≤20 dB HL at all frequencies is indicated to be normalhearing; >20 dB HL (e.g., 25 dB HL or greater); SNHL above 4,000 Hz(e.g., 6 or 8 kHz) is indicated to be grade 1; >20 dB HL SNHL at 4,000Hz and above is indicated to be grade 2; >20 dB HL SNHL at 2,000 Hz or3,000 Hz and above is indicated to be grade 3; and >40 dB HL (e.g., 45dB HL or more) SNHL at 2,000 Hz is indicated to be grade 4.

The tinnitus functional index is a questionnaire-based index thatquantitates the severity of tinnitus symptoms. See Henry J A et al.,Audiology Today 26(6): 40-48 (2014). The index is defined as follows: amean score of 14 (range of 0-17) is no tinnitus, a mean score of 21indicates a low levels of tinnitus; a mean score of 42 is a moderatetinnitus; a mean score of 65 is high levels of tinnitus, and a meanscore of 78 is large levels of tinnitus. Ranges can be broken down into<25 is relatively mild tinnitus or no tinnitus, 25-50 indicatessignificant problems with tinnitus, and >50 indicates levels of tinnitusthat require aggressive intervention.

In some embodiments, the ototoxicity is measured by measuring hearingloss at one or more frequencies comprising 500 Hz, 1,000 Hz, 2,000 Hz,4,000 Hz, or 8,000 Hz or a combination of frequencies thereof, wherein achange in hearing is computed relative to baseline measures prior to thepatient receiving a platinum based chemotherapeutic or sodiumthiosulfate or both. In some aspects, an increase in ototoxicity can bedetermined as a reduction in hearing measured by a 20 dB loss at asingle frequency; a reduction in hearing measured by a 10 dB loss at twoconsecutive frequencies; or a loss of response at three consecutive testfrequencies where responses were previously obtained. In some furtheraspects, an increase in ototoxicity is measured as a reduction inbilateral high-frequency hearing characterized by: a <40 dB hearing lossat all frequencies, which indicates a grade 0 or minimal hearing loss; a≥40 dB hearing loss at 8,000 Hz only, which indicates a grade 1 or mildhearing loss; a ≥40 dB hearing loss at 4,000 Hz and above, whichindicates a grade 2 or moderate hearing loss; a ≥40 dB hearing loss at2,000 Hz and above, which indicates a grade 3 or marked hearing loss; ora ≥40 dB hearing loss at 1,000 Hz and above, which indicates a grade 4or severe hearing loss. In still some further aspects, an increase inototoxicity is measured as a reduction in hearing characterized by: a≤20 dB hearing loss at all frequencies, which indicates a grade 0hearing loss; a >20 dB HL above 4,000 Hz, which indicates a grade 1hearing loss; a >20 dB HL at 4,000 Hz and above, which indicates a grade2 hearing loss; a >20 dB HL at 2,000 Hz or 3,000 Hz, which indicates agrade 3 hearing loss; or a >40 dB HL at 2,000 Hz and above, whichindicates a grade 4 hearing loss. In some other aspects, an increase inototoxicity can be measured by a reduction in a tinnitus functionalindex.

The administration of STS to pediatric patients being treated with aplatinum based chemotherapeutic was found to not exacerbate renal orother toxicities. Thus, in some aspects, patients receiving STS do notexperience more severe or an increased incidence rate of adverse eventscompared to patients not administered STS. These adverse events comprisegrade 3 or grade 4 neutropenia, reduced glomerular filtration rates,increased serum creatinine, infection, hypomagnesemia, hypernatremia,vomiting, or nausea. In some other aspects, pediatric patientsadministered STS do not have a reduction in relapse free survival oroverall survival compared to patients not administered STS.

The methods described herein are well suited for reducing or preventingototoxicity or reducing the likelihood of incurring ototoxicity in anypediatric patient of any age. Therefore, in some embodiments describedthe pediatric patient being treated following the methods describedherein may be a new born or the pediatric patient may about 1 month old,about 2 months old, about 3 months old, about 4 months old, about 5months old, about 6 months old, about 7 months old, about 8 months old,about 9 months old, about 10 months old, about 11 months old, about 12months old, about 1 year old, about 1.5 years old, about 2 years old,about 2.5 years old, about 3 years old, about 3.5 years old, about 4years old, about 4.5 years old, about 5 years old, about 5.5 years old,about 6 years old, about 6.5 years old, about 7 years old, about 7.5years old, about 8 years old, about 8.5 years old, about 9 years old,about 9.5 years old, about 10 years old, about 10.5 years old, about 11years old, about 11.5 years old, about 12 years old, about 12.5 yearsold, about 13 years old, about 13.5 years old, about 14 years old, about14.5 years old, about 15 years old, about 15.5 years old, about 16 yearsold, about 16.5 years old, about 17 years old, about 17.5 years old,about 18 years old, about 18.5 years old, about 19 years old, about 19.5years old, about 20 years old, about 20.5 years old, or about 21 yearsold. In some aspects, the pediatric patient is about 12 years of age orless, about 5 years of age or less, about 2 years of age or less, orabout 1 year of age or less.

Indications and Usage

In one embodiment, sodium thiosulfate for injection as described hereinis indicated for the prevention of ototoxicity induced by cisplatin(CIS) chemotherapy in patients 1 month to <18 years of age withlocalized, non-metastatic, solid tumors.

In one embodiment, sodium thiosulfate for injection as described hereinis administered as a 15-minute infusion, 6 hours after the completion ofeach CIS administration, when CIS is infused for no longer than 6 hours.In one aspect, the recommended dose of sodium thiosulfate for injectionas described herein for the prevention of CIS-induced ototoxicity isweight-based and normalized to body surface area as shown below.

Dose of STS Volume of STS Subject Body Weight for Injection forInjection >10 kg 12.8 g/m²  160 mL/m² 5 to 10 kg 9.6 g/m² 120 mL/m² <5kg 6.4 g/m²  80 mL/m²Dosage Forms and Strengths

Sodium thiosulfate for injection as described herein is a sterilesolution containing 80 mg/mL (8 g/100 mL) of sodium thiosulfate forintravenous (IV) administration in a single-use vial.

Sodium thiosulfate for injection as described herein is administered asa 15-minute infusion, 6 hours after the completion of each CISadministration, when CIS is infused for no longer than 6 hours.Pre-treatment with antiemetics is recommended to reduce the incidence ofnausea and vomiting.

The timing of sodium thiosulfate for injection administration relativeto CIS chemotherapy is critical, because earlier treatment may reduceCIS efficacy, and later treatment may not be as effective in preventingototoxicity.

Sodium thiosulfate for injection should only be administered followingCIS infusions of 1 to 6 hours. Do not use sodium thiosulfate forinjection if the CIS infusion exceeds 6 hours, or if a subsequent CISinfusion is planned within 6 hours.

CIS STS Minimum time to Infusion  

  Delay  

  Infusion  

  next CIS Infusion 1-6 hrs 6 hrs 15 min 6 hrsContraindications

Sodium thiosulfate for injection as described herein is contraindicated:in patients with a known hypersensitivity to sodium thiosulfate (STS) orany of the inactive ingredients in sodium thiosulfate for injection; andin neonates under the age of 1 month due to the risk of hypernatremia.

DESCRIPTION

Sodium thiosulfate anhydrous, the active ingredient, is an inorganicsalt with reducing agent properties. It is a white to off-whitecrystalline solid, that is soluble in water, but insoluble in alcohol.The aqueous solution is practically neutral with a pH ranging from 6.5to 9.0. The molecular formula is Na₂S₂O₃. It has a molecular weight of158.11 g/mol. The structural formula is:

Sodium thiosulfate for injection as described herein is a sterile,preservative-free, clear solution for intravenous use. Each vialcontains 80 mg/mL sodium thiosulfate anhydrous (United StatesPharmacopeia, USP), water for injection (USP), boric acid or sodiumphosphate as a buffer component, and sodium hydroxide and/orhydrochloric acid for pH adjustment.

Mechanism of Action

Cisplatin-induced ototoxicity is caused by irreversible damage to haircells in the cochlea. The cochlea is very sensitive to oxidative stress,which has been shown to be involved in CIS induced hearing loss. Themechanism of STS protection against ototoxicity is not fully understood,but may include increasing levels of endogenous antioxidants, scavengingreactive oxygen species, and direct interaction between CIS and thethiol group in STS. STS has the ability to enter cells at least partlythrough the sodium sulfate cotransporter 2 and can cause intracellulareffects such as the increase in antioxidant glutathione levels andinhibition of intracellular oxidative stress.

Pharmacodynamics

STS prevented ototoxicity in at doses equivalent to 6.4 to 12.8 g/m²sodium thiosulfate for injection. In preliminary clinical studies, lowerSTS dose levels (equivalent to 5.1 g/m² sodium thiosulfate forinjection) resulted in low maximum plasma levels (3.9 mM) and did notshow hearing protection.

The 6-hour delay of STS treatment after CIS chemotherapy is important tocircumvent potential interference with the anti-tumor activity of CIS,which is supported by data from non-clinical studies and preliminaryclinical studies. During CIS infusion, bioactive unbound CIS distributesto cancer cells; it is cleared through renal excretion and rapid bindingto proteins leading to inactivation of its tumoricidal activity. Theinitial decline of unbound platinum in plasma is rapid, with a half-liferanging from 0.6 to 1.35 hours. Together with the fact that STSdistribution is largely limited to extracellular spaces, administrationof sodium thiosulfate for injection 6 hours after completion of each CISinfusion should prevent a tumor protective effect of STS. As shown instudies, treatment 6 hours after completion of each CIS infusion did notaffect survival.

Based on the half-life of STS in plasma, a negligible amount remains 6hours after completion of an STS infusion. Therefore, subsequent CISinfusions should be administered no sooner than 6 hours after thecompletion of a sodium thiosulfate infusion to avoid a pharmacodynamicinteraction.

A 12.8 g/m² dose of sodium thiosulfate for injection delivers a sodiumload of 162 mmol/m². Doses of STS equivalent to this resulted in asmall, transient increase in serum sodium levels. When evaluated usingnon-compartmental pharmacokinetic analysis at the recommended sodiumthiosulfate for injection dose levels, this transient increase in sodiumwas independent of age, body surface area, body weight, total daily STSdose, or CIS cycle.

Pharmacokinetics

Absorption

STS is poorly absorbed after oral administration and has to beadministered intravenously. At the end of an STS intravenous infusion,plasma levels of STS are maximal and decline rapidly thereafter with ahalf-life of approximately 20 to 50 minutes. A return to pre-dose levelsoccurs within 3 to 6 hours after infusion. More than 95% of STSexcretion in urine occurs within the first 4 hours after administration.There is no plasma accumulation when STS is administered on 2consecutive days.

In children and adults, the maximum STS plasma levels after a 15-minuteinfusion of a dose equivalent to 12.8 g/m² sodium thiosulfate forinjection was approximately 13.3 mM. STS plasma levels change in a doseproportional manner. Age did not appear to influence the maximum plasmalevels of STS or the decline afterwards. A population pharmacokineticmodel incorporating growth and maturation variables for the pediatricpopulation showed that the predicted STS plasma levels at the end ofinfusion were consistent across the recommended sodium thiosulfate forinjection dose levels for the indicated age and body weight ranges.

Distribution

STS does not bind to human plasma proteins. STS is an inorganic salt andthiosulfate anions do not readily cross membranes. Hence, the volume ofdistribution appears largely confined to extracellular spaces andestimated at 0.23 L/kg in adults. In animals, STS has been found todistribute to the cochlea. Distribution across the blood brain barrieror placenta appears absent or limited. Thiosulfate is an endogenouscompound ubiquitously present in all cells and organs. Endogenous serumthiosulfate levels were 5.5±1.8 μM in adult volunteers.

Elimination

Metabolism: Metabolites of STS have not been determined as part ofclinical studies. Thiosulfate is an endogenous intermediate product ofsulfur-containing amino acid metabolism. Thiosulfate metabolism does notinvolve CYP enzymes; it is metabolized through thiosulfate sulfurtransferase and thiosulfate reductase activity to sulfite, which israpidly oxidized to sulfate.

Excretion: STS (thiosulfate) is excreted through glomerular filtration.After administration, STS (thiosulfate) levels in urine are high, andapproximately half of the STS dose is retrieved unchanged in urine,nearly all excreted within the first 4 hours after administration. STSrenal clearance related well with inulin clearance as a measure for theGFR.

Excretion of endogenously produced thiosulfate in bile was very low anddid not increase after STS administration. No mass balance studies havebeen performed, but it is expected that non renal clearance will mainlyresult in renal excretion of sulfates. A small part of the sulfanesulfur of STS may become part of endogenous cellular sulfur metabolism.

Drug Product and Storage and Handling

Sodium thiosulfate for injection is supplied as 100 mL of a clear,colorless, sterile solution in flint glass vials with 20-mm stoppers andcapped with aluminum overseals. Each 100 mL of sodium thiosulfate forinjection contains sodium thiosulfate, anhydrous (80 mg per mL) forintravenous administration (8 g of STS per vial).

Sodium thiosulfate for injection should be stored at controlled roomtemperature, between 15° C. and 30° C.

It will be apparent to one of ordinary skill in the relevant art thatsuitable modifications and adaptations to the compositions,formulations, methods, processes, reactions, and applications describedherein can be made without departing from the scope of any embodimentsor aspects thereof. The compositions and methods provided are exemplaryand are not intended to limit the scope of any of the specifiedembodiments. All of the various embodiments, aspects, and optionsdisclosed herein can be combined in any and all variations oriterations. The scope of the compositions, formulations, methods, andprocesses described herein include all actual or potential combinationsof embodiments, aspects, options, examples, and preferences hereindescribed. The exemplary compositions and formulations described hereinmay omit any component, substitute any component disclosed herein, orinclude any component disclosed elsewhere herein. The ratios of the massof any component of any of the compositions or formulations disclosedherein to the mass of any other component in the formulation or to thetotal mass of the other components in the formulation are herebydisclosed as if they were expressly disclosed. Should the meaning of anyterms in any of the patents or publications incorporated by referenceconflict with the meaning of the terms used in this disclosure, themeanings of the terms or phrases in this disclosure are controlling.Furthermore, the foregoing discussion discloses and describes merelyexemplary embodiments. All patents and publications cited herein areincorporated by reference herein for the specific teachings thereof.

EXAMPLES Example 1

Synthesis Process

An overview of the synthesis process is shown in FIG. 1. The synthesisof sodium thiosulfate (wet) was accomplished by reacting 1.0 moleequivalent of aqueous sodium sulfite with 1.1 mole equivalents ofelemental sulfur in the presence of 0.00013 mole equivalents ofcetylpyridinium chloride (CPC) at 90° C. for up to 3 hr as shown inScheme I.

In some instances, the reaction was heated to about 90° C. and wascompleted upon reaching 90° C. Without being bound by any theory, thereaction rate appears to depend on the size, surface area, andsolubility of the sulfur (e.g., fine powder reacts more rapidly thanflakes). Once the reaction was complete, the mixture was cooled to 25°C., filtered through a 10 μm filter, and transferred to acrystallization vessel. The sodium thiosulfate solution was then cooledto less than 2° C., and acetone was slowly added over at least 1 h whilemaintaining a temperature of <2° C. (except during the initialnucleation where a 5-7° C. exotherm was observed). The slurry was thenheld at <2° C. for at least 0.5 h and stepwise transferred to a filterdryer in portions. The slurry was filtered to the point where thefiltrate drops just below the level of the cake after each portion ofslurry was added; this process minimized cracking of the resulting cake.The cake was then washed twice with acetone and filtered until no liquidexited. The resulting cake of “wet sodium thiosulfate” was then dried at45° C. overnight while mixing under vacuum. The term “wet sodiumthiosulfate” as used herein refers to sodium thiosulfate that has notbeen dehydrated.

Dehydration

Filtered methanol was used to charge a crystallization vessel and heatedto 60° C. This warm methanol was then transferred into a filter dryercontaining the overnight-dried “wet sodium thiosulfate” cake. The cakewas slurried with the hot methanol and the filtrate was removed bypressure. A second charge of hot methanol was added, mixed, and thefiltrate removed. This was followed by two additional washes withambient temperature methanol and vacuum drying at 55° C. overnight. Thisprocess produced anhydrous sodium thiosulfate.

Example 2

Milling

Some batches of the anhydrous sodium thiosulfate were milled using a jetmill to a particle size distribution of 50% of the population, d₅₀, of10-20 μm. The unmilled anhydrous sodium thiosulfate synthesized asdescribed herein has a particle size distribution of 50-75 μm. Withoutbeing bound by any theory, milling increased the surface area of thesodium thiosulfate particles and was believed to permit enhancedevaporation of any residual solvent(s).

Example 3

Analysis

The dried and/or milled anhydrous sodium thiosulfate was collected atstored at ambient temperature. Samples were analyzed for sodium sulfite,sulfur, acetone, and methanol levels among other trace elements usingHPLC, inductively coupled plasma mass spectrometry (ICP-MS), FTIRspectroscopy, and X-ray powder diffraction. Specifications andrepresentative data for anhydrous sodium thiosulfate synthesized asdescribed using the foregoing methods are shown in Table 4.

TABLE 4 Specifications and Representative STS Parameters ParameterSpecification Result Appearance White to off-white solid, White tooff-white solid, free of particulate free of particulate Cadmium ≤0.10μg/g ≤0.05 μg/g Lead ≤0.25 μg/g ≤0.125 μg/g Arsenic ≤0.75 μg/g ≤0.375μg/g Mercury ≤0.15 μg/g ≤0.075 μg/g Cobalt ≤0.25 μg/g ≤0.125 μg/gVanadium ≤0.50 μg/g ≤0.25 μg/g Nickel ≤1.00 μg/g ≤0.50 μg/g Lithium≤12.5 μg/g ≤6.25 μg/g Antimony ≤4.50 μg/g ≤2.25 μg/g Copper ≤15.0 μg/g≤7.5 μg/g Methanol ≤1500 ppm 841 ppm Water ≤3% (w/w) 0.07% (w/w) FTIRConforms to known Conforms Indentification reference spectrum XRPDResults Report result See FIGS. 2 and 3. Differential ScanningCalorimetry Onset Temp Report result 330.6° C. Peak Temp Report result334.0° C. Heat Flow Report result −122.73 J/g Total Aerobic ≤100 CFU ≤1CFU Microbial Count Total Combined ≤100 CFU ≤1 CFU Yeast/Mold Count HPLCRetention time conforms to Conforms reference standard Assay, as is98-102% (w/w) 98.50% Total Impurities ≤1.5% (w/w) ≤1.5% (w/w)

Example 4

X-Ray Powder Diffraction Characterization

Samples of anhydrous sodium thiosulfate as described herein or sodiumthiosulfate pentahydrate were analyzed by X-Ray Powder Diffraction(XRPD). Between 2 and 50 mg of sample were placed in a zero backgroundholder coated with a thin layer of petroleum jelly and leveled with aglass plate. XRPD data was acquired using a Bruker D8 X-rayDiffractometer from 2° to 40° 20 with a 0.05° step size (1 sec/step)with copper Kα radiation (40 kV). The sample was rotated at 15 RPMduring acquisition. Peak picking was performed in Materials Data Jade9.7.0 software.

The XRPD patterns for anhydrous sodium thiosulfate or sodium thiosulfatepentahydrate are shown in FIGS. 2A and 2B, respectively; XRPD peaks arelisted in Tables 5 and 6, respectively. Significant peaks are shown inbold. An overlay of the anhydrous sodium thiosulfate pattern in 2A(bottom pattern) and sodium thiosulfate pentahydrate pattern in 2B (toppattern) is shown in FIG. 3.

TABLE 5 Anhydrous Sodium Thiosulfate X-ray Powder Diffraction Peaks2-theta (deg.) d(Å) Height Height Percent (%) 10.523 8.4000 7.6 4.815.138 5.8481 36.6 23.2 17.712 5.0036 5.9 3.7 19.021 4.6620 1.8 1.119.702 4.5023 29.8 18.9 20.199 4.3927 0.5 0.3 21.086 4.2099 157.9 10021.490 4.1315 14.3 9.1 21.848 4.0647 5.2 3.3 23.767 3.7407 3.7 2.324.288 3.6617 5.7 3.6 25.986 3.4261 3.8 2.4 26.260 3.3909 2.8 1.7 27.4023.2522 11.8 7.4 28.012 3.1828 4.6 2.9 28.962 3.0805 67.5 42.8 30.4652.9318 145.4 92.1 31.814 2.8105 6.8 4.3 32.516 2.7514 6.0 3.8 33.1472.7005 84.0 53.2 34.740 2.5802 2.8 1.7 34.916 2.5676 4.0 2.5 35.7862.5071 4.5 2.9 36.365 2.4686 1.7 1.1 37.029 2.4258 3.1 2.0 37.396 2.402811.2 7.1 37.499 2.3964 9.2 5.8 38.157 2.3566 11.0 7.0 38.260 2.3505 5.93.8 Significant peaks are bolded. Peaks unique to or prominent in theanhydrous sodium thiosulfate form are: 10.52, 15.13, 19.70, 21.49,21.84, 28.96, 30.46, 33.15, 37.40, and 38.16.

TABLE 6 Sodium Thiosulfate Pentahydrate X-ray Powder Diffraction Peaks2-theta (deg.) d(Å) Height Height Percent (%) 8.344 10.5876 2.4 1.39.189 9.6164 2.6 1.5 12.129 7.2914 1.8 1.0 14.747 6.0022 2.1 1.2 14.9465.9225 2.4 1.3 15.438 5.7351 41.6 23.3 15.906 5.5674 6.2 3.5 16.5345.3573 178.8 100 17.388 5.0961 1.6 0.9 18.408 4.8159 16 8.9 18.9614.6767 0.5 0.3 19.790 4.4825 1.2 0.7 20.014 4.433 11.1 6.2 20.251 4.38161.7 1.0 21.249 4.1780 42.4 23.7 23.448 3.7909 3.6 2.0 24.123 3.6863 16.29.1 24.35 3.6524 5.6 3.1 24.847 3.5805 18.7 10.4 25.435 3.4991 7.0 3.925.933 3.4329 5.5 3.1 26.189 3.4000 1.0 0.5 27.049 3.2938 3.6 2.0 27.4623.2453 9.1 5.1 27.974 3.1870 19.4 10.9 30.438 2.9343 5.9 3.3 31.0452.8783 11.2 6.2 31.691 2.8212 4.4 2.4 32.654 2.7401 4.7 2.6 33.1982.6964 1.8 1.0 33.805 2.6494 6.9 3.9 34.151 2.6233 1.2 0.7 34.400 2.60494.0 2.2 35.016 2.5605 0.1 0.0 35.243 2.5445 0.1 0.1 36.097 2.4862 0.50.3 36.656 2.4496 3.7 2.1 37.167 2.4171 2.2 1.2 38.281 2.3493 3.0 1.738.573 2.3322 0.9 0.5 38.966 2.3095 6.5 3.6 39.488 2.2802 1.1 0.6 39.6222.2728 1.5 0.8 Significant peaks are bolded.

Example 4

Sodium Thiosulfate Binding Capacity Assay

A high performance liquid chromatography ultra-violet spectroscopy(HPLC-UV) assay was developed to quantitate the binding capacity ofthiosulfate for cisplatin. This method permits comparison of the bindingcapacity of different lots of sodium thiosulfate or pharmaceuticalcompositions containing sodium thiosulfate. The HPLC-UV method directlymeasures the diminution of cisplatin over time in the presence ofvarying concentrations of sodium thiosulfate.

The method uses a Waters Acquity H-Class HPLC system with an ImtaktScherzo SW-C18 mixed mode column. The HPLC method conditions areoutlined in Table 7. The method has a linear response covering cisplatinconcentrations from 3.3 μM (0.001 mg/mL) to 666 μM (0.2 mg/mL). Thisrange covers greater than two orders of magnitude at dose-relevantconcentrations.

TABLE 7 Sodium Thiosulfate HPLC-UV Method HPLC System: Waters AcquityH-Class Column: Imtakt Scherzo SW C18 Mixed-Mode, 150 mm × 3 mm, 3 μmMPA: 0.5 mM Ammonium formate in 9:1 H₂O:Acetonitrile, pH 4 MPB: 200 mMAmmonium formate in 7:3 H₂O:Acetonitrile, pH 4 Detection: UV 220 nmColumn Temperature: 35° C. Diluent: 0.9% NaCl in H₂O Flow Rate: 0.4mL/min Gradient Conditions Time (min) MPA (%) MPB (%) 0 100 0 3 100 04.5 90 10 6.5 90 10 6.6 100 0 10.0 100 0

The assay was performed by mixing equal volumes containing 333 μM, 400μM, or 666 μM of sodium thiosulfate with 666 μM cisplatin (ratios of5:1, 6:1, or 10:1 thiosulfate:cisplatin, respectively). Each sample wastransferred to an HPLC vial and placed in an autosampler chamber held at24° C. Samples were injected onto the HPLC system approximately every 30minutes to obtain 4 time-points for each sample. A gradient was run andthe retention time and peak area were obtained. The decrease inconcentration of cisplatin was monitored over time to obtain a reactionrate (e.g., the slope of the line, [cisplatin]/min) and calculatedhalf-life (the time to reach 333/2 μM cisplatin based on the slope ofthe line). Control samples contained 333 μM cisplatin.

Exemplary results are summarized in Table 8 and FIG. 4.

TABLE 8 Sodium Thiosulfate-Cisplatin Binding Assay Results CisplatinConcentration (μM) Time (min) Cntrl Cntrl Cntrl 5:1 5:1 6:1 6:1 10:110:1 4 328.7 333.1 328.1 323.7 323.7 319.5 5 325.4 324.5 320.3 37 317.9322.3 316.3 294.2 294.0 269.4 38 286.4 293.2 278.5 70 295.4 308.6 303.6266.8 268.0 235.2 71 259.8 266.2 239.6 103 286.9 296.6 292.5 243.7 245.3205.6 104 235.6 240.5 209.3 Linear Regression of Cisplatin Conc. vs.Time Control (n = 3) 5:1 (n = 2) 6:1 (n = 2) 10:1 (n = 2) Slope(Cisplatin −0.40 −0.80 −0.87 −1.13 Area/min) R² 0.99 1.00 0.99 0.99y-int 332 325 326 321 Half-life (min) 423 198 184 136

Example 5

Formulation Preparation

The process for preparing the sodium thiosulfate formulation is shown inFIG. 5. Anhydrous sodium thiosulfate was dissolved in sodium phosphatebuffer (˜10 mM sodium phosphate). An exemplary sodium thiosulfatepharmaceutical formulation is shown in Table 9. The pH was adjusted toca. 6.5 with NaOH and HCl or phosphoric acid. The solution was filteredtwice through 0.22 μm filters. The filtered solution was filled intoglass vials. The vials were sealed with septa and crimped. The sealedfilled vials were autoclaved at 121° C., 15 psi for at least 0.5 h tosterilize the contents. The vials were inspected, labeled, and stored atambient temperature.

TABLE 9 Exemplary Sodium Thiosulfate Formulation Component Mass/VolumeMolarity Sodium thiosulfate, anhydrous 80.0 mg/mL   0.5 M Sodiumphosphate, monobasic, monohydrate 1.23 mg/mL 0.0087 M Sodium phosphate,dibasic, anhydrous 0.16 mg/mL 0.0012 M Total phosphate buffer 1.39 mg/mL 0.01 M Hydrochloric acid q.s. q.s. Sodium hydroxide q.s. q.s. Final pH:7.0-8.0

Example 6

The manufacturing process for anhydrous sodium thiosulfate as describedherein comprises the following steps:

Step 1: Chemical synthesis of sodium thiosulfate, aqueous;

Step 2: Crystallization of sodium thiosulfate (wet) and washing withacetone;

Step 3: Dehydration and isolation of anhydrous sodium thiosulfate; and

Step 4: Packaging.

The synthesis route is presented in Scheme II and each step is describedfurther below.

Synthesis of Sodium Thiosulfate

The synthesis of aqueous sodium thiosulfate was accomplished by reacting1.0 mole equivalents of aqueous sodium sulfite with 1.1 mole equivalentsof solid elemental sulfur (trace metals) under aqueous conditions at95±5° C. in the presence of catalytic amounts of cetylpyridiniumchloride (0.00013 mole equivalents) to form sodium thiosulfate. SeeScheme II. The reaction completeness was verified after 6 hours bymeasuring the amount of residual sodium sulfite present (e.g., <0.15%w/w sulfite by HPLC-CAD). The finished reaction was then cooled to 20±5°C. for at least 3 hours and held at 20±5° C. for at least 1 hour. Theproduct solution was passed through a 1 μm bag filter followed by a 0.45μm cartridge polishing filter to remove any residual sulfur whiletransferring the product to a crystallization vessel.

Crystallization of Sodium Thiosulfate (Wet)

The product solution was cooled in a crystallization vessel to 0±5° C.with vigorous agitation, and about 35% of the total acetone was addedand mixed for at least 20 min while maintaining a temperature of no morethan 10° C. After incubation at 0±5° C. for about 5 to about 20 min, asodium thiosulfate seed crystal was added and the crystallization wasperformed at 0±5° C. for about 5 to about 20 min. The remaining quantityof acetone was added while the temperature was maintained at 0±5° C. Theslurry was then held at 0±5° C. for at least 0.5 hour and thentransferred to a filter dryer. The filtrate was removed by pressurefiltration. The slurry was filtered to the point where the filtratedrops just below the level of the cake after each portion of slurry wasadded; this process minimized cracking of the resulting cake. The cakewas then washed twice with acetone and blown with N₂ gas until no liquidexited. The resulting cake of “wet sodium thiosulfate” was then dried atambient temperature and atmospheric pressure with N₂ blowing through thecake for at least 1 hour. The term “wet sodium thiosulfate” or “sodiumthiosulfate (wet)” as used herein refers to sodium thiosulfate that hasnot been dehydrated.

Dehydration and Isolation of Anhydrous Sodium Thiosulfate

Filtered methanol, heated to 60±5° C. was charged into the filter dryercontaining the dried “wet” sodium thiosulfate material and agitatedcontinuously at 45±5° C. for at least 3 hours. The material was blownwith nitrogen for at least 2 hours. The temperature was then raised to55±5° C. and the solid is dried under vacuum for at least 24 hours.Afterwards, the residual solvents were tested using gas chromatographyfor volatile impurities. The anhydrous sodium thiosulfate material wascooled to 20±5° C. under slight nitrogen pressure.

Packaging

Immediately after cooling, the anhydrous sodium thiosulfate drugsubstance was transferred into HDPE drums that were double lined withLDPE bags and contained a desiccant between the LDPE liners. The drumswere purged with nitrogen gas prior to sealing.

Manufacturing specifications are shown in Table 10.

TABLE 10 Anhydrous Sodium Thiosulfate Manufacturing SpecificationsSection I: General Information Name Sodium Thiosulfate SpecificationDrug Substance Anhydrous Classification Molecular Weight 158.11 g/molStructure Storage Condition Room Temperature Retest Date 12 months from(25° C.) manufacture Bulk Primary HDPE Keg with Sample Heat-sealed foilpouch Storage Container Heat-sealed foil Container(s) containingdouble-lined pouch containing poly bag with desiccant double-lined polybag with desiccant Test Sample Release: 5 grams Retention Sample N/AAmount MET: 15 grams Amount Section II: Testing Attributes and MethodsSpecification Test Method Attribute (Limit/Range/Description) AppearanceInternal Appearance White to off-white solid, free of particulatesIdentification by cUSP (197A) Identification FTIR conforms to referencespectrum Identification cUSP Sodium Identification meets (191) therequirements Identification by IC Internal Identification Retention timeof Thiosulfate in sample corresponds to that of reference standardImpurities by HPLC Internal Residual Sulfite NMT 0.5% Residual SulfateNMT 1.5% Assay by IC Internal Assay, solvent free 97.5-102.5% andanhydrous basis NMT not more than.

The following pages show manufacturing specifications of anhydroussodium thiosulfate produced by the method described above in 10 kg and30 kg batches (Tables 11 and 12).

TABLE 11 Specifications for Anhydrous Sodium Thiosulfate Manufactured at10 kg Scale Test Method Specification 1-A 1-B 1-C 1-D Appearance VisualWhite to off- White to off- White to off- White to off- White to off-white solid, white solid, white solid, white solid, white solid, free offree of free of free of free of particulates particulates particulatesparticulates particulates Identification cUSP Conforms to ConformsConforms Conforms Conforms by FTIR <197A> reference spectrumIdentification cUSP Meets the Present Present Present Present Sodiumrequirements <191> Identification Ion Retention time Conforms ConformsConforms Conforms by IC chroma- of Thiosulfate tography in samplecorresponds to that of reference standard Assay by IC Ion 97.5-102.5%99.1% 101.1% 101.3% 100.4% chroma- (as is) tography Impurities by IonResidual Sulfite: Sulfite: Sulfite: Sulfite: IC chroma- Sulfite: ND NDND ND tography NMT 0.15% Residual Sulfate: Sulfate: Sulfate: Sulfate:Sulfate: 0.56% 0.56% 0.54% 0.6% NMT 1.5% Water Karl NMT 3.0% 0.1% 0.1%0.1% 0.1% Content Fischer (w/w) USP <921> 1c OVI by GC GC Acetone: ≤2500Acetone: Acetone: <100 Acetone: Acetone: ppm ND ppm ND ND Methanol:≤1500 MeOH: MeOH: <100 MeOH: <100 MeOH: ppm ND ppm ppm ND PolymorphicXRPD Sample pattern Conforms Conforms Conforms Conforms Form conformswith reference spectrum Elemental ICP-MS Cd: ≤0.1 ppm Cd: <0.05 Cd:<0.05 Cd: <0.05 Cd: <0.05 Impurities or Pb: ≤0.25 ppm Pb: <0.125 Pb:<0.125 Pb: <0.125 Pb: <0.125 Elemental As: ≤0.7 5 ppm As: <0.375 As:<0.375 As: <0.375 As: <0.375 Limit Hg: ≤0.15 ppm Hg: <0.075 Hg: <0.075Hg: <0.075 Hg: <0.075 Analysis Co: ≤0.25 ppm Co: <0.125 Co: <0.125 Co:<0.125 Co: <0.125 V: ≤0.5 ppm V: <0.25 V: <0.25 V: <0.25 V: <0.25 Ni: ≤1ppm Ni: <0.5 Ni: <0.5 Ni: <0.5 Ni: <0.5 Li: ≤12.5 ppm Li: <2.25 Li:<2.25 Li: <2.25 Li: <2.25 Sb: ≤4.5 ppm Sb: <6.25 Sb: <6.25 Sb: <6.25 Sb:<6.25 Cu: ≤15.0 ppm Cu: <7.5 Cu: <7.5 Cu: <7.5 Cu: <7.5 Microbial USP<61> Total Aerobic 2 CFU/g <1 CFU/g 3 CFU/g <1 CFU/g EnumerationMicrobial Tests Count: ≤100 cfu/g Total Yeasts <1 CFU/g <1 CFU/g <1CFU/g <1 CFU/g and Molds Count: ≤100 cfu/g Endotoxin USP <85> NMT 5.0EU/g <0.5 EU/g <0.5 EU/g <0.5 EU/g <0.5 EU/g Test Method Specification1-E 1-F 2-A 2-B Appearance Visual White to off- White to off- White tooff- White to off- White to off- white solid, white solid, white solid,white solid, white solid, free of free of free of free of free ofparticulates particulates particulates particulates particulatesIdentification cUSP Conforms to Conforms Conforms Conforms Conforms byFTIR <197A> reference spectrum Identification cUSP Meets the PresentPresent Present Present Sodium requirements <191> Identification IonRetention time Conforms Conforms Conforms Conforms by IC chroma- ofThiosulfate tography in sample corresponds to that of reference standardAssay by IC Ion 97.5-102.5% 99.3% 99.5% 99.9% 101.2% chroma- (as is)tography Impurities by Ion Residual Sulfite: Sulfite: Sulfite: Sulfite:IC chroma- Sulfite: ND ND ND ND tography NMT 0.15% Residual Sulfate:Sulfate: Sulfate: Sulfate: Sulfate: 0.6% 0.55% 0.55% 0.52% NMT 1.5%Water Karl NMT 3.0% 0.1% 0.0% 0.1% 0.04% Content Fischer (w/w) USP <921>1c OVI by GC GC Acetone: ≤2500 Acetone: Acetone: Acetone: Acetone: ppmND ND ND ND Methanol: ≤1500 MeOH: MeOH: MeOH: MeOH: ppm ND ND ND NDPolymorphic XRPD Sample pattern Conforms Conforms Conforms Conforms Formconforms with reference spectrum Elemental ICP-MS Cd: ≤0.1 ppm Cd: <0.05Cd: <0.05 Cd: <0.05 Cd: <0.05 Impurities or Pb: ≤0.25 ppm Pb: <0.125 Pb:<0.125 Pb: <0.125 Pb: <0.125 Elemental As: ≤0.7 5 ppm As: <0.375 As:<0.375 As: <0.375 As: <0.375 Limit Hg: ≤0.15 ppm Hg: <0.075 Hg: <0.075Hg: <0.075 Hg: <0.075 Analysis Co: ≤0.25 ppm Co: <0.125 Co: <0.125 Co:<0.125 Co: <0.125 V: ≤0.5 ppm V: <0.25 V: <0.25 V: <0.25 V: <0.25 Ni: ≤1ppm Ni: <0.5 Ni: <0.5 Ni: <0.5 Ni: <0.5 Li: ≤12.5 ppm Li: <2.25 Li:<2.25 Li: <2.25 Li: <2.25 Sb: ≤4.5 ppm Sb: <6.25 Sb: <6.25 Sb: <6.25 Sb:<6.25 Cu: ≤15.0 ppm Cu: <7.5 Cu: <7.5 Cu: <7.5 Cu: <7.5 Microbial USP<61> Total Aerobic <1 CFU/g <1 CFU/g <1 CFU/g <1 CFU/g EnumerationMicrobial Tests Count: ≤100 cfu/g Total Yeasts <1 CFU/g <1 CFU/g <1CFU/g <1 CFU/g and Molds Count: ≤100 cfu/g Endotoxin USP <85> NMT 5.0EU/g <0.5 EU/g <0.5 EU/g <0.5 EU/g <0.5 EU/g NMT: not more than.

TABLE 12 Specifications for Anhydrous Sodium Thiosulfate Manufactured at30 kg Scale Test Method Specification 1 2 3 Appearance Visual White tooff-white White solid, free of White solid, free of White to off-whitesolid, free of particulates particulates solid, free of particulatesparticulates Identification by cUSP (197A) Conforms to Conforms ConformsConforms FTIR reference spectrum Identification cUSP Sodium Meets thePresent Present Present (191) requirements Identification by IonRetention time of Conforms Conforms Conforms IC chromatographyThiosulfate in sample corresponds to that of reference standard Assay byIC Ion 97.5-102.5% 98.9% 98.3% 98.1% chromatography (as is) Impuritiesby IC Ion Residual Sulfite: Sulfite: ND Sulfite: ≤0.10% Sulfite: NDchromatography NMT 0.15% Sulfate: 0.9% Sulfate: 1.0% Sulfate: 0.9%Residual Sulfate: NMT 1.5% Water Content Karl Fischer USP NMT 3.0%  0.0% 0.1%  0.0% (921) 1c (w/w) OVI by GC GC Acetone: ≤2500 ppm Acetone: NDAcetone: ND Acetone: ND Methanol: ≤1500 ppm MeOH: ≤100 ppm MeOH: 133 ppmMeOH: 238 ppm Polymorphic XRPD Sample pattern Conforms Conforms ConformsForm conforms with reference spectrum Elemental ICP-MS Cd: ≤0.1 ppmImpurities or Pb: ≤0.25 ppm Elemental Limit As: ≤0.75 ppm Analysis Hg:≤0.15 ppm Co: ≤0.25 ppm V: ≤0.5 ppm Ni: ≤1 ppm Li: ≤12.5 ppm Sb: ≤4.5ppm Cu: ≤15.0 ppm Microbial USP (61) Total Aerobic   ≤1 CFU/g   ≤1 CFU/g  ≤1 CFU/g Enumeration Microbial Count:   ≤1 CFU/g   ≤1 CFU/g   ≤1 CFU/gTests ≤100 cfu/g Total Yeasts and Molds Count: ≤100 cfu/g Endotoxin USP(85) NMT 5.0 EU/g ≤0.5 CFU/g ≤0.5 CFU/g ≤0.5 CFU/g ND Not determined;NMT not more than.

Example 7

The anhydrous sodium thiosulfate synthesized as described herein is acrystalline material that exhibits sharp XRPD peaks (FIG. 2A) andbirefringent particles with blade- and plate-like crystal morphology.Thermal analysis by differential scanning calorimetry (DSC) showed asingle, sharp endotherm with an onset of 331.4° C. that is the apparentmelting temperature (FIG. 4A). In the thermogravimetric analysis (TGA),there was negligible weight loss from ambient temperature to 162° C.From 162° C. to 309° C., there was a weight loss of 14.81% followed byan onset of decomposition at 436° C. (FIG. 4A). The dynamic vaporsorption (DVS) isotherm showed a minimal weight change uponequilibration to 0% relative humidity (FIG. 4B). Upon sorption, theexhibits a weight gain of 165%. Hysteresis was observed upon desorption,with a weight loss of 51%.

By comparison, the DSC thermogram of sodium thiosulfate pentahydrateshowed multiple endothermic events with maxima at 56, 111, 131, and 141°C., with a melt onset at 331° C. A 45.33% weight loss was observed inTGA from 25° C. until −300° C., followed by decomposition at 456° C. TheDVS isotherm showed a 27% weight loss upon drying. The material had aweight gain of 81% upon sorption. Hysteresis was observed upondesorption, with a weight loss of 51%.

Example 8

A process for preparing the sodium thiosulfate formulation for injectionis shown in FIG. 5. Anhydrous sodium thiosulfate was dissolved in boratebuffer (˜4 mM boric acid). An exemplary sodium thiosulfatepharmaceutical formulation is shown in Table 13. The pH was adjusted toca. 8.6-8.8 with NaOH and HCl. The solution was filtered twice through0.22 μm filters. The filtered solution was filled into glass vials. Thevials were sealed with septa, aluminum rings, and crimped. The sealedfilled vials were autoclaved at 121° C., 15 psi for at least 0.5 h tosterilize the contents. The vials were inspected, labeled, and stored atambient temperature.

TABLE 13 Exemplary Sodium Thiosulfate Formulation Component Mass/VolumeMolarity Sodium thiosulfate, 80.0 mg/mL  0.5 M anhydrous Boric acid 0.25mg/mL 0.004 M Hydrochloric acid q.s. q.s. Sodium hydroxide q.s. q.s.Final pH: 8.6-8.8

Table 14 shows the manufacturing specifications for the sodiumthiosulfate formulation for injection.

TABLE 14 Sodium Thiosulfate For Injection Drug Product SpecificationsParameters Method/Laboratory Acceptance Criteria Appearance VisualClear, colorless solution essentially free of particulate matterIdentification: Thiosulfate HPLC Retention time of thiosulfate in sampleagrees with retention time of reference material Clarity and Degree ofPh. Eur. 2.2.1 NMT Reference suspension 1 Opalescence of Liquids Degreeof Coloration of a Liquid Ph. Eur. 2.2.2 Identification STS by FTIR USP(197) Conforms to reference spectrum Identification for Sodium US (191)Meets requirements pH USP (791) 7.0-9.0 Ph. Eur. 2.2.3 Assay IC USRelease: 90.0-110.0% label claim Stability: 90.0-110.0% label claim EURelease: 95.0-105.0% label claim Stability: 90-100.0% lable claimSulfite IC NMT 0.15% Sulfate IC NMT 1.5% Sulfur HPLC-UV NMT 0.15%Extractable USP (1) NLT 100 mL Volume Ph. Eur 2.9.17 Particulate USP(788) 10 μm: ≤3000 Matter Ph. Eur. 2.9.19 25 μm: ≤3000 Sterility USP(71) No growth observed Ph. Eur. 2.6.1 Bacterial Endotoxin USP (85) NMTnot more than

Example 9

Exemplary sodium thiosulfate pharmaceutical formulations are shown inTables 15-23. These formulations are prepared as described herein.

TABLE 15 Exemplary Sodium Thiosulfate Formulation Component Mass/VolumeMolarity Sodium thiosulfate, anhydrous 80.0 mg/mL   0.5 M Sodiumphosphate, monobasic, monohydrate 1.23 mg/mL 0.0012 M Sodium phosphate,dibasic, anhydrous 0.16 mg/mL 0.0087 M Total phosphate buffer 1.39 mg/mL 0.01 M Hydrochloric acid q.s. q.s. Sodium hydroxide q.s. q.s. Final pH:7.5-8.0

TABLE 16 Exemplary Sodium Thiosulfate Formulation Component Mass/VolumeMolarity Sodium thiosulfate, anhydrous 80.0 mg/mL   0.5 M Sodiumphosphate, monobasic, monohydrate 2.46 mg/mL  0.017 M Sodium phosphate,dibasic, anhydrous 0.31 mg/mL 0.0023 M Total phosphate buffer 2.77 mg/mL 0.02 M Hydrochloric acid q.s. q.s. Sodium hydroxide q.s. q.s. Final pH:7.5-8.0

TABLE 17 Exemplary Sodium Thiosulfate Formulation Component Mass/VolumeMolarity Sodium thiosulfate, anhydrous 80.0 mg/mL  0.5 M Boric acid 0.25mg/mL 0.004 M Hydrochloric acid q.s. q.s. Sodium hydroxide q.s. q.s.Final pH: 8.6-8.8

TABLE 18 Exemplary Sodium Thiosulfate Formulation Component Mass/VolumeMolarity Sodium thiosulfate, anhydrous 80.0 mg/mL  0.5 M Glycine  1.5mg/mL 0.02 M Hydrochloric acid q.s. q.s. Sodium hydroxide q.s. q.s.Final pH: 8.5-8.9

TABLE 19 Exemplary Sodium Thiosulfate Formulation Component Mass/VolumeMolarity Sodium thiosulfate, anhydrous 80.0 mg/mL  0.5 M Glycine  2.3mg/mL 0.03 M Hydrochloric acid q.s. q.s. Sodium hydroxide q.s. q.s.Final pH: 8.5-8.9

TABLE 20 Exemplary Sodium Thiosulfate Formulation Component Mass/VolumeMolarity Sodium thiosulfate, anhydrous 80.0 mg/mL  0.5 M Glycine  3.8mg/mL 0.05 M Hydrochloric acid q.s. q.s. Sodium hydroxide q.s. q.s.Final pH: 8.5-8.9

TABLE 21 Exemplary Sodium Thiosulfate Formulation Component Mass/VolumeMolarity Sodium thiosulfate, anhydrous 80.0 mg/mL  0.5 MTris(hydroxymethyl)aminomethane 1.21 mg/mL 0.01 M (Tromethane)Hydrochloric acid q.s. q.s. Sodium hydroxide q.s. q.s. Final pH: 8.5-8.9

TABLE 22 Exemplary Sodium Thiosulfate Formulation Component Mass/VolumeMolarity Sodium thiosulfate, anhydrous 80.0 mg/mL  0.5 MTris(hydroxymethyl)aminomethane 2.42 mg/mL 0.02 M (Tromethane)Hydrochloric acid q.s. q.s. Sodium hydroxide q.s. q.s. Final pH: 8.5-8.9

TABLE 23 Exemplary Sodium Thiosulfate Formulation Component Mass/VolumeMolarity Sodium thiosulfate, anhydrous 80.0 mg/mL  0.5 MTris(hydroxymethyl)aminomethane 3.63 mg/mL 0.03 M (Tromethane)Hydrochloric acid q.s. q.s. Sodium hydroxide q.s. q.s. Final pH: 8.5-8.9

What is claimed:
 1. A pharmaceutical composition comprising aqueousanhydrous sodium thiosulfate, wherein the aqueous anhydrous sodiumthiosulfate is at a concentration of about 0.5 M and further comprisingabout 0.004 M boric acid.
 2. The pharmaceutical composition of claim 1,wherein the pharmaceutical composition has a total volume of about 100mL.
 3. The pharmaceutical composition of claim 1, wherein thepharmaceutical composition further comprises hydrochloric acid.
 4. Thepharmaceutical composition of claim 2, wherein the pharmaceuticalcomposition further comprises hydrochloric acid.
 5. The pharmaceuticalcomposition of claim 1, wherein the pharmaceutical composition furthercomprises sodium hydroxide.
 6. The pharmaceutical composition of claim2, wherein the pharmaceutical composition further comprises sodiumhydroxide.
 7. The pharmaceutical composition of claim 1, wherein thepharmaceutical composition has a pH between about 5 and about 9.5. 8.The pharmaceutical composition of claim 1, wherein the pharmaceuticalcomposition has a pH between about 6.5 and about 8.9.
 9. Thepharmaceutical composition of claim 1, wherein the pharmaceuticalcomposition has a pH between about 8.6 and about 8.8.